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docs_md/articles/abdominal-wall-mass_d51e2268-67b6-4a60-9222-f5a86f61ddec.md

@@ -0,0 +1,253 @@
+---
+title: "Abdominal Wall Mass"
+docid: "d51e2268-67b6-4a60-9222-f5a86f61ddec"
+authors:
+  - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+    value: "Siva P. Raman, MD"
+breadcrumbs:
+  -
+    name: "Gastrointestinal"
+    slug: "gastrointestinal"
+    treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+  -
+    name: "Differential Diagnosis"
+    slug: "differential-diagnosis"
+    treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+  -
+    name: "Abdominal Wall"
+    slug: "abdominal-wall"
+    treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+  -
+    name: "Anatomically Based Differentials"
+    slug: "anatomically-based-differentials"
+    treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+  -
+    name: "Abdominal Wall Mass"
+    slug: "abdominal-wall-mass"
+    treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "258ccc6a-0370-4b08-adc4-dfc3ef9a1ce6"
+imageCount: 18
+lastUpdated: "07/15/22"
+pageDescription: "Abdominal Wall Mass"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Abdominal Wall Mass"
+pageTitle: "Abdominal Wall Mass | STATdx"
+enhancedTitle: "Abdominal Wall Mass"
+type: "DDX"
+references: true
+breadcrumbs:
+  - "Gastrointestinal"
+  - "Differential Diagnosis"
+  - "Abdominal Wall"
+  - "Anatomically Based Differentials"
+  - "Abdominal Wall Mass"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+  
+  
+    - Given limitations of clinical examination, imaging plays important role in differentiating true soft tissue masses from hernias, vascular abnormalities, and normal variants
+    - Most soft tissue masses have nonspecific appearance and may require biopsy or excision for diagnosis
+- ## Helpful Clues for Common Diagnoses
+  
+  
+    - **Abdominal Wall Hernias**
+          - **Inguinal hernia**
+                  - Most common external hernia, which extends into groin anterior to horizontal plane of pubic tubercle
+                  - Divided into direct (arises anteromedial to inferior epigastric vessels) and indirect (arises superolateral to inferior epigastric vessels) subtypes
+          - **Ventral hernia**
+                  - Broad term describing acquired or congenital hernias through anterior and lateral abdominal wall
+                  - Midline hernias include epigastric (above umbilicus) and hypogastric (below umbilicus) hernias
+                  - Incisional hernias occur at prior surgical incision sites
+          - **Umbilical hernia**
+                  - Hernias arising at midline in upper 1/2 of umbilical ring, which can be congenital or acquired
+                  - Very common incidental finding on imaging, although usually small and asymptomatic
+          - **Spigelian hernia**
+                  - Hernia through defect lateral to rectus sheath (inferior and lateral to umbilicus) often covered by external oblique muscle and aponeurosis
+          - **Femoral hernia**
+                  - Groin hernia extending medial to femoral vessels with frequent compression of femoral vein
+                  - Most common in older female patients with very high risk of strangulation and incarceration
+          - **Lumbar hernia**
+                  - Hernia through defect in lumbar muscle or thoracolumbar fascia
+                  - Can be congenital or acquired with many acquired due to incisions in flank region for renal surgery
+    - **Abdominal Wall Abscess**
+          - Loculated fluid collection (± internal gas) with peripheral enhancement and surrounding edema/fat stranding
+          - Differentiate drainable abscess from diffuse, nondrainable edema/fluid (cellulitis/phlegmon)
+          - Presence of gas-containing abdominal wall abscess in close contiguity with bowel tethered to abdominal wall raises possibility of enterocutaneous fistula
+    - **Sebaceous Cyst**
+          - Common incidental finding, appearing as small, round/oval, well-encapsulated cyst near skin surface
+          - Should be low density and nonenhancing without surrounding subcutaneous edema/fat stranding
+    - **Lipoma**
+          - Common incidental mass in subcutaneous tissues and between muscle planes, demonstrating uniform fat density with no internal soft tissue component
+          - Differentiate from liposarcoma, which demonstrates internal complexity and soft tissue component
+          - Confident diagnosis may be difficult on US, but mass should have similar echogenicity to subcutaneous fat
+    - **Keloid**
+          - Benign fibrotic scar tissue or tissue overgrowth at site of soft tissue injury (i.e., surgical incision or trauma)
+          - Usually asymptomatic but can be painful or pruritic
+          - No clear imaging features to allow differentiation of large keloid from other soft tissue masses
+    - **Hematoma**
+          - Heterogeneous, high-density blood products, which gradually evolve and become lower in density over time
+          - More diffuse subcutaneous blood products may reflect subcutaneous ecchymosis
+    - **Paraumbilical Varices**
+          - Common portosystemic collaterals in patients with severe cirrhosis and portal hypertension
+          - Serpiginous enhancing structures that connect to recanalized paraumbilical vein near falciform ligament
+          - May be visible/palpable at skin (i.e., caput medusae)
+    - **Injection Site**
+          - Common incidental finding usually secondary to injection of heparin, insulin, or other medications
+          - Small nodular foci with ectopic gas, blood, or fluid
+          - May chronically evolve into injection granulomas, appearing as rounded or linear foci of soft tissue or calcification (most common in buttocks)
+    - **Calcified Scar**
+          - Heterotopic ossification (myositis ossificans traumatica) can occur at abdominal incision sites and is most common in linear alba after midline abdominal incision
+          - Ossified scar in incision can resemble rib (with both cortex and medulla)
+    - **Muscle Asymmetry (Mimic)**
+          - May be mistaken for mass and are common secondary to prior surgery, paralysis, myopathy, etc.
+    - **Melanoma**
+          - 5th most common new cancer in US, but imaging typically not utilized for diagnosis of primary tumor
+          - Most commonly multiple small subcutaneous nodules, although rarely presents as solitary abdominal wall mass
+          - Homogeneous enhancement ± hyperintense on T1 MR
+- ## Helpful Clues for Less Common Diagnoses
+  
+  
+    - **Endometriosis**
+          - Endometriosis implants may be seen within incision sites after prior C-section or hysterectomy
+          - Typically appears as solid, spiculated subcutaneous mass with variable enhancement (usually hypointense on T1 and hyperintense on T2 MR)
+          - May be associated with clinical history of cyclical pain (corresponding with menstruation) at incision site
+    - **Calcinosis Syndromes**
+          - Dystrophic: Calcifications may be due to tissue injury response, such as implanted medical device, connective tissue diseases (scleroderma, dermatomyositis, CREST), severe pancreatitis, or fat necrosis
+          - Metastatic: Most often in patients with calcium-phosphate imbalance (renal failure, milk-alkali syndrome)
+          - Tumoral calcification: Large globular deposits of calcification near joints
+    - **Soft Tissue Metastases**
+          - Most common malignancies to metastasize to soft tissues are melanoma and renal cell carcinoma
+          - Soft tissue nodule or mass(es) in subcutaneous fat or muscle with enhancement similar to primary tumor
+          - Easily overlooked on CT if careful survey of soft tissues not undertaken, but often more apparent on PET
+          - Tumor may also be implanted at site of surgery (probably more common with laparoscopic surgery) or biopsy
+                  - Surgical seeding can also occur with benign lesions, including uterine fibroids and ectopic splenic tissue
+    - **Lymphoma and Leukemia**
+          - Cutaneous T-cell lymphoma (a.k.a. mycosis fungoides or Sézary syndrome)
+                  - Skin 2nd most common site of extranodal lymphoma (after GI tract)
+                  - Skin involvement may be difficult to appreciate on imaging unless unusually nodular or mass-like
+          - Subcutaneous panniculitis-like T-cell lymphoma
+                  - Manifests as site of soft tissue induration/infiltration or as discrete nodules
+          - Leukemia cutis (i.e., chloroma or granulocytic sarcoma)
+          - Primary B-cell cutaneous lymphomas more likely to present as solitary isolated skin lesion
+          - Posttransplant lymphoproliferative disorders (PTLD) can rarely manifest in subcutaneous soft tissues
+    - **Desmoid**
+          - Benign locally aggressive neoplasm, which can be intraabdominal or extraabdominal (e.g., abdominal wall)
+          - Abdominal wall lesions most frequently arise from rectus or oblique muscles, especially at incision sites
+          - Major risk factors include prior surgery, trauma, Gardner syndrome, and familial adenomatous polyposis
+          - Variable appearance but typically solid, well-defined, hypoenhancing, heterogeneously high signal on T2 and low signal on T1 MR
+    - **Sarcoma**
+          - Malignant mesenchymal soft tissue tumors, which encompass wide range of different histologic subtypes
+          - May be difficult to differentiate from other soft tissue masses based on imaging alone, although most sarcomas tend to be larger and more heterogeneous with frequent necrosis (± distant metastatic disease)
+          - Different subtypes of sarcomas cannot be differentiated on imaging with any accuracy
+    - **Rhabdomyolysis**
+          - Muscle necrosis in response to wide variety of causes, including crush injury, seizures, statin medications, etc.
+          - Involved muscles on CT generally appear either normal or abnormally hypodense (due to edema)
+          - MR more sensitive, with muscles demonstrating T2 hyperintensity and enlargement, as well as hyperenhancement (can appear ring-like or mass-like)
+          - Commonly leads to severe renal damage due to release of myoglobin into bloodstream
+    - **Pancreatic Panniculitis**
+          - Subcutaneous fat necrosis seen with pancreatitis and pancreatic adenocarcinoma (due to ↑ serum lipase)
+          - Manifest as small nodular foci of predominantly fat density on CT and hyperechoic on US
+    - **Kaposi Sarcoma**
+          - Most common AID-related vascular neoplasm in Western world, presenting as either diffuse infiltration of skin or discrete subcutaneous nodules
+
+## References
+
+# Selected References
+
+1. [Ballard DH et al: Imaging of abdominal wall masses, masslike lesions, and diffuse processes. Radiographics. 40(3):684-706, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32330085%5Bpmid%5D)
+1. [Draghi F et al: Abdominal wall sonography: a pictorial review. J Ultrasound. 23(3):265-78, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32125676%5Bpmid%5D)
+1. [Kania LM et al: Interpreting body MRI cases: classic findings in pelvic MRI. Abdom Radiol (NY). 45(9):2916-30, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32607649%5Bpmid%5D)
+1. [Mao A et al: Post-cesarean section abdominal wall endometrioma. Cureus. 12(8):e10088, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33005511%5Bpmid%5D)
+1. [Youssef AT: The ultrasound of subcutaneous extrapelvic endometriosis. J Ultrason. 20(82):e176-80, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=33365153%5Bpmid%5D)
+1. [Hensen JH et al: Abdominal wall endometriosis: clinical presentation and imaging features with emphasis on sonography. AJR Am J Roentgenol. 186(3):616-20, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16498086%5Bpmid%5D)
+1. [Zafar HM et al: Anterior abdominal wall hernias: findings in barium studies. Radiographics. 26(3):691-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16702448%5Bpmid%5D)
+1. [Aguirre DA et al: Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 25(6):1501-20, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16284131%5Bpmid%5D)
+1. [Shadbolt CL et al: Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 21 Spec No:S261-71, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11598262%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![Axial CECT shows a right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of nonobstructed small bowel.](images/app.statdx.com_image_thumbnail_dcf3e531-1181-43fa-8a2a-588ef14eb1de_annotated_true_size_900_quality_90_7a3efacf7c9ea3cb8a17271f24a81f1ac6d54288.jpg)
+**Abdominal Wall Hernias**
+*Axial CECT shows a right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of nonobstructed small bowel.*
+
+![Axial CECT shows a right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of nonobstructed small bowel.](images/app.statdx.com_image_thumbnail_dcf3e531-1181-43fa-8a2a-588ef14eb1de_size_174_quality_85_42e13993a266e5c5b9631020a51cf6d50a0dadd2.jpg)
+**Abdominal Wall Hernias**
+*Axial CECT shows a right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of nonobstructed small bowel.*
+
+![Axial CECT shows an encapsulated, near water density mass <img src='img/arrows/WS.png'/> in the left buttock. Sebaceous cysts are a common incidental finding and, when demonstrating a classic appearance, do not require further follow-up or evaluation.](images/app.statdx.com_image_thumbnail_db465646-b13b-46e3-b8c8-fff0d9d410ee_annotated_true_size_900_quality_90_e90f5b74fd45053329f673ddac2aa4fb2173f43d.jpg)
+**Sebaceous Cyst**
+*Axial CECT shows an encapsulated, near water density mass <img src='img/arrows/WS.png'/> in the left buttock. Sebaceous cysts are a common incidental finding and, when demonstrating a classic appearance, do not require further follow-up or evaluation.*
+
+![Coronal CECT shows a large, fat-containing mass <img src='img/arrows/WS.png'/> within the right lateral abdominal wall, compatible with a simple lipoma. Note the absence of any complexity or soft tissue component within the mass.](images/app.statdx.com_image_thumbnail_867bb3a5-784d-4e8d-8603-c601ca7c6591_annotated_true_size_900_quality_90_d1ee3b6f052805fe30d695273da832413ecb40fc.jpg)
+**Lipoma**
+*Coronal CECT shows a large, fat-containing mass <img src='img/arrows/WS.png'/> within the right lateral abdominal wall, compatible with a simple lipoma. Note the absence of any complexity or soft tissue component within the mass.*
+
+![Axial CECT shows an acute, high-density subcutaneous hematoma <img src='img/arrows/WS.png'/> in a patient with recent trauma.](images/app.statdx.com_image_thumbnail_b422e3b5-b955-4730-a2f7-80de7ef8313b_annotated_true_size_900_quality_90_60f4c3ba19a3ac9b82fda6230fa6163bf664ae2a.jpg)
+**Hematoma**
+*Axial CECT shows an acute, high-density subcutaneous hematoma <img src='img/arrows/WS.png'/> in a patient with recent trauma.*
+
+![Axial CECT in a patient with cirrhosis and portal hypertension shows subcutaneous varices  <img src='img/arrows/WS.png'/>  overlying the anterior abdominal wall, representing a caput medusae.](images/app.statdx.com_image_thumbnail_483306f0-5c17-4692-af94-9cc54a31394b_annotated_true_size_900_quality_90_a6c7fd42a98d41f0f44c9c75f4fead2143667463.jpg)
+**Hematoma**
+*Axial CECT in a patient with cirrhosis and portal hypertension shows subcutaneous varices  <img src='img/arrows/WS.png'/>  overlying the anterior abdominal wall, representing a caput medusae.*
+
+![Axial T1 C+ MR shows an enhancing mass  <img src='img/arrows/WS.png'/> in the left anterior pelvic wall, found to represent a scar endometrioma in this patient status post prior laparoscopic pelvic surgery.](images/app.statdx.com_image_thumbnail_274e5ffb-66ba-419f-b739-d5d1926492e0_annotated_true_size_900_quality_90_65a5ccca881e3559d74b927e2d72f2e70a4d57c4.jpg)
+**Paraumbilical Varices**
+*Axial T1 C+ MR shows an enhancing mass  <img src='img/arrows/WS.png'/> in the left anterior pelvic wall, found to represent a scar endometrioma in this patient status post prior laparoscopic pelvic surgery.*
+
+![Sagittal CECT shows a soft tissue mass  <img src='img/arrows/WS.png'/>  intimately associated with the umbilicus, ultimately found at biopsy to represent endometriosis.](images/app.statdx.com_image_thumbnail_aa3aa78d-9eae-4519-a639-e519972a8d75_annotated_true_size_900_quality_90_2578e7f4720c90c850a99fa468e611a165efc7dd.jpg)
+**Endometriosis**
+*Sagittal CECT shows a soft tissue mass  <img src='img/arrows/WS.png'/>  intimately associated with the umbilicus, ultimately found at biopsy to represent endometriosis.*
+
+![Axial CECT shows a hypodense mass <img src='img/arrows/WS.png'/> in the midline anterior abdominal wall, proven to represent a metastasis from the patient's known primary colon cancer.](images/app.statdx.com_image_thumbnail_8771eaba-7e00-46de-85ff-8869f6981272_annotated_true_size_900_quality_90_af11b7af72ca74ddb38c6dfab41cfa6da6df64bc.jpg)
+**Soft Tissue Metastases**
+*Axial CECT shows a hypodense mass <img src='img/arrows/WS.png'/> in the midline anterior abdominal wall, proven to represent a metastasis from the patient's known primary colon cancer.*
+
+![Axial CECT shows a hypodense mass <img src='img/arrows/WS.png'/>  in the abdominal wall musculature, representing a metastasis from the patient's known colon cancer.](images/app.statdx.com_image_thumbnail_7ca98799-5a7e-443e-832f-d6287f6e1000_annotated_true_size_900_quality_90_b17ca806245233c6c715adec68d13736728f5f90.jpg)
+**Soft Tissue Metastases**
+*Axial CECT shows a hypodense mass <img src='img/arrows/WS.png'/>  in the abdominal wall musculature, representing a metastasis from the patient's known colon cancer.*
+
+![Axial CECT shows a biopsy-proven chloroma <img src='img/arrows/WS.png'/> in the right anterior abdominal wall in a patient with known leukemia.](images/app.statdx.com_image_thumbnail_9419367d-042b-4cd5-8947-033e90982a6f_annotated_true_size_900_quality_90_ccc25bf34e82f7ef058dbd8d0e4f260b5ab95b6a.jpg)
+**Lymphoma and Leukemia**
+*Axial CECT shows a biopsy-proven chloroma <img src='img/arrows/WS.png'/> in the right anterior abdominal wall in a patient with known leukemia.*
+
+![Axial CECT shows multiple large, hypodense masses <img src='img/arrows/WS.png'/> in the pelvic subcutaneous soft tissues in a patient with known familial polyposis, representing desmoid tumors.](images/app.statdx.com_image_thumbnail_9e00082b-5017-45d3-9ff8-01a09d411ee5_annotated_true_size_900_quality_90_746f3fbf30048c72d3c914438d5b2279f205a986.jpg)
+**Desmoid**
+*Axial CECT shows multiple large, hypodense masses <img src='img/arrows/WS.png'/> in the pelvic subcutaneous soft tissues in a patient with known familial polyposis, representing desmoid tumors.*
+
+![Axial CECT shows a hypodense mass  <img src='img/arrows/WS.png'/>  in the right anterior abdominal wall, ultimately found to represent a desmoid tumor.](images/app.statdx.com_image_thumbnail_4745fc41-165c-4f88-be4c-a1275a6e7f6a_annotated_true_size_900_quality_90_440d75af6a855673bfc42f569b85563d1b2f5813.jpg)
+**Desmoid**
+*Axial CECT shows a hypodense mass  <img src='img/arrows/WS.png'/>  in the right anterior abdominal wall, ultimately found to represent a desmoid tumor.*
+
+![Axial CECT shows a large, rapidly growing mass  <img src='img/arrows/WS.png'/>  in the left anterior abdominal wall, representing a primary soft tissue sarcoma (malignant fibrous histiocytoma).](images/app.statdx.com_image_thumbnail_d511ed2e-5b98-4317-b781-483982263f43_annotated_true_size_900_quality_90_539326d68a8d44c647592429ecb325b5fdbdba45.jpg)
+**Sarcoma**
+*Axial CECT shows a large, rapidly growing mass  <img src='img/arrows/WS.png'/>  in the left anterior abdominal wall, representing a primary soft tissue sarcoma (malignant fibrous histiocytoma).*
+
+![Axial T1 C+ FS MR shows a highly invasive, large tumor in the buttock <img src='img/arrows/WS.png'/>, which enhances significantly. This lesion proved on biopsy to be a high-grade epithelioid sarcoma.](images/app.statdx.com_image_thumbnail_0cf82c02-784a-4d5a-aec2-33e4ace01062_annotated_true_size_900_quality_90_b80b091cc5e43c478e3fb373fad15e1da414bf4a.jpg)
+**Sarcoma**
+*Axial T1 C+ FS MR shows a highly invasive, large tumor in the buttock <img src='img/arrows/WS.png'/>, which enhances significantly. This lesion proved on biopsy to be a high-grade epithelioid sarcoma.*
+
+
+### Additional Images
+
+![Axial CECT shows a colostomy <img src='img/arrows/WC.png'/> with extensive varices <img src='img/arrows/WO.png'/> in the parastomal region. These develop in patients with portal hypertension (e.g., following colectomy for primary sclerosing cholangitis with cirrhosis).](images/app.statdx.com_image_thumbnail_b593a259-7880-4bc0-893a-3cede1985b33_annotated_true_size_900_quality_90_d23259d664dcbe385fadc731b06bfaabbe8cb8ed.jpg)
+**Paraumbilical Varices**
+*Axial CECT shows a colostomy <img src='img/arrows/WC.png'/> with extensive varices <img src='img/arrows/WO.png'/> in the parastomal region. These develop in patients with portal hypertension (e.g., following colectomy for primary sclerosing cholangitis with cirrhosis).*
+
+![Axial CECT shows prominent parastomal varices <img src='img/arrows/WO.png'/>.](images/app.statdx.com_image_thumbnail_8c098b02-5027-496c-85b7-dfc1c0889128_annotated_true_size_900_quality_90_bdf0b980cc2f900b68830370651ec8624b994092.jpg)
+**Paraumbilical Varices**
+*Axial CECT shows prominent parastomal varices <img src='img/arrows/WO.png'/>.*
+
+![Axial CECT shows a cirrhotic liver and a large parumbilical varix <img src='img/arrows/WS.png'/>.](images/app.statdx.com_image_thumbnail_9e3d0aa0-fd13-41a0-ab30-fa6d15df2e4b_annotated_true_size_900_quality_90_c2842bb418190bd3fa83cbe913eb2df98ad4e271.jpg)
+**Paraumbilical Varices**
+*Axial CECT shows a cirrhotic liver and a large parumbilical varix <img src='img/arrows/WS.png'/>.*
+
+![Axial CECT shows continuation of the parumbilical varix with collaterals in the rectus muscles and subcutaneous fat <img src='img/arrows/WS.png'/> (caput medusae).](images/app.statdx.com_image_thumbnail_ab9bd043-a8b8-404a-810a-1b42e2c14ca8_annotated_true_size_900_quality_90_23892e164e44984ceb75a0cb49b8421994ace331.jpg)
+**Paraumbilical Varices**
+*Axial CECT shows continuation of the parumbilical varix with collaterals in the rectus muscles and subcutaneous fat <img src='img/arrows/WS.png'/> (caput medusae).*
+

docs_md/articles/cnvii-facial-nerve_98cb2d45-e64c-4295-9662-3470cd46513a.md

@@ -0,0 +1,298 @@
+---
+title: "CNVII (Facial Nerve)"
+docid: "98cb2d45-e64c-4295-9662-3470cd46513a"
+authors:
+  - key: "1fa14dfd-71ea-4960-908e-e720313bc63a"
+    value: "Santhosh Gaddikeri, MD"
+  - key: "94f835c8-fa13-4e8a-995b-53048e6b0605"
+    value: "Philip R. Chapman, MD"
+breadcrumbs:
+  -
+    name: "Head and Neck"
+    slug: "head-and-neck"
+    treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+  -
+    name: "Anatomy"
+    slug: "anatomy"
+    treeNodeId: "678bc99d-d43e-45e6-9c8d-9fa5a7648616"
+  -
+    name: "Cranial Nerves"
+    slug: "cranial-nerves"
+    treeNodeId: "5cb153f5-b8a6-4321-a37d-ac4e2a31be47"
+  -
+    name: "CNVII (Facial Nerve)"
+    slug: "cnvii-facial-nerve"
+    treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "0baca093-e8fa-4711-9ecc-05167315d50b"
+documentVersionId: "1e66f9a4-6069-4b31-b464-8a6b37d40f11"
+imageCount: 39
+lastUpdated: "12/06/23"
+pageDescription: "CNVII (Facial Nerve)"
+pageKeywords: "Head and Neck, Anatomy, Cranial Nerves, CNVII (Facial Nerve)"
+pageTitle: "CNVII (Facial Nerve) | STATdx"
+enhancedTitle: "CNVII (Facial Nerve)"
+type: "ANATOMY"
+breadcrumbs:
+  - "Head and Neck"
+  - "Anatomy"
+  - "Cranial Nerves"
+  - "CNVII (Facial Nerve)"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+  
+  
+    - Facial nerve (CNVII)
+- ## Synonyms
+  
+  
+    - 7th cranial nerve
+- ## Definitions
+  
+  
+    - CNVII: Cranial nerve carrying motor nerves to muscles of facial expression; parasympathetics to lacrimal, submandibular, & sublingual glands; and taste from anterior 2/3 of tongue
+
+# IMAGING ANATOMY
+
+- ## Overview
+  
+  
+    - Mixed nerve: Motor, parasympathetic, and special sensory (taste)
+    - 2 roots: Motor and sensory (nervus intermedius) roots
+          - Nervus intermedius exits lateral brainstem between motor root of CNVII and CNVIII, hence its name
+    - 3 nuclei and 4 segments: Intraaxial, cisternal, intratemporal, and extracranial (parotid)
+    - Blood supply from petrosal branch of **middle meningeal artery** & stylomastoid branch of **posterior auricular artery**
+- ## Nuclei and Intraaxial Segment
+  
+  
+    - 3 nuclei (1 motor, 2 sensory)
+    - **Motor nucleus of facial nerve**
+          - Located in ventrolateral pontine tegmentum
+          - Efferent fibers loop dorsally around CNVI nucleus in floor of 4th ventricle, forming facial colliculus
+          - Fibers then course anterolaterally to exit lateral brainstem at pontomedullary junction
+    - **Superior salivatory nucleus**
+          - Located lateral to CNVII motor nucleus in pons
+          - Efferent **parasympathetic fibers** exit brainstem posterior to CNVII as nervus intermedius
+                  - To submandibular, sublingual, and lacrimal glands
+    - **Solitarius tract nucleus**
+          - Taste sensation fibers from anterior 2/3 of tongue
+          - **Cell bodies** of these fibers in **geniculate ganglion**
+          - Fibers travel within nervus intermedius
+- ## Cisternal Segment
+  
+  
+    - 2 roots in cisternal CNVII
+          - Larger motor root anteriorly
+          - Smaller sensory nervus intermedius posteriorly
+    - Emerge from lateral brainstem at **root exit zone** in pontomedullary junction to enter cerebellopontine angle (CPA) cistern
+          - CNVIII exits brainstem posterior to CNVII
+    - 2 roots join together and pass anterolaterally through CPA cistern with CNVIII to internal auditory canal (IAC)
+- ## Intratemporal Segment
+  
+  
+    - Further divided in temporal bone into 4 segments: IAC, labyrinthine, tympanic, & mastoid
+    - **IAC segment**: Porus acusticus to IAC fundus; anterosuperior position above crista falciformis
+    - **Labyrinthine segment**: Connects fundal CNVII to geniculate ganglion (anterior genu)
+    - **Tympanic segment**: Connects anterior to posterior genu, passing under lateral semicircular canal
+    - **Mastoid segment**: Inferiorly directed from posterior genu to stylomastoid foramen
+- ## Extracranial Segment
+  
+  
+    - Main CNVII exits skull base through **stylomastoid foramen** to enter parotid space
+    - Parotid CNVII passes lateral to retromandibular vein
+    - Ramifies within parotid, passes anteriorly to innervate muscles of facial expression
+- ## CNVII Branches
+  
+  
+    - **Greater (superficial) petrosal nerve**
+          - Arises at geniculate ganglion, passes anteromedially, exits temporal bone via facial hiatus
+          - Carries **parasympathetic** fibers to **lacrimal gland**
+          - Joined by deep petrosal nerve (sympathetic fibers) in foramen lacerum to form **vidian nerve**
+    - **Nerve to stapedius**
+          - Arises from high mastoid segment of CNVII behind pyramidal eminence
+          - Provides **motor** innervation to **stapedius muscle**
+    - **Chorda tympani**
+          - Arises from lower mastoid segment
+          - Courses across middle ear to exit anterior temporal bone
+          - Carries **taste** fibers from **anterior 2/3 of tongue**
+                  - Fibers travel with lingual branch of mandibular division of trigeminal nerve
+          - Carries **parasympathetic** fibers to **submandibular & sublingual glands** via submandibular ganglion
+    - **Terminal motor branches** to muscles of facial expression
+          - Superior to inferior: Temporal, zygomatic, buccal, mandibular, cervical
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Recommendations
+  
+  
+    - High-resolution bone CT best for intratemporal CNVII
+    - MR for intraaxial, cisternal, IAC, and extracranial segments
+          - 3D heavily T2 sequence, thin-section axial and coronal T2, precontrast and postcontrast fat-saturated T1
+    - Include brainstem, CPA cistern, IAC, temporal bone, and **parotid**when MR completed for CNVII palsy
+    - Do not image typical Bell palsy
+- ## Imaging Pitfalls
+  
+  
+    - Enhancement of geniculate ganglion, tympanic & mastoid segments of CNVII normal on postcontrast T1 MR; can be asymmetric intensity of enhancement on right & left
+          - Secondary to circumneural arteriovenous plexus
+    - Cisternal, IAC, labyrinthine, and parotid segments do not normally enhance on MR
+          - Faint enhancement may be seen depending on MR scanner, sequence, & type of contrast used
+          - Be familiar with normal images in different institutions
+    - Always check parotid in peripheral CNVII paralysis
+- ## Clinical Issues
+  
+  
+    - Facial nerve paralysis can be central or peripheral
+          - **Central**: Supranuclear injury; paralysis of contralateral muscles of facial expression with **forehead sparing**
+          - **Peripheral**: Injury to CNVII from brainstem nucleus peripherally, resulting in paralysis of all ipsilateral muscles of facial expression
+                  - Lesion proximal to geniculate ganglion; lacrimation, sound dampening and taste are affected
+                  - CNVI involved; check pons for lesion
+                  - CNVIII involved; check CPA-IAC for lesion
+                  - Lacrimation, sound dampening, and taste are variably affected; temporal bone lesion possible
+                  - Lacrimation, sound dampening, and taste are spared; extracranial CNVII implicated
+
+ 965f30b5-41e0-4767-82e6-813a492e4281
+
+
+## Images
+
+
+### Graphics
+
+![Axial graphic shows CNVII nuclei. The motor nucleus sends out its fibers to circle the CNVI nucleus before reaching the root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. The solitary tract nucleus receives taste information from the anterior 2/3 of the tongue.](images/app.statdx.com_image_thumbnail_1f7e56c2-da7a-4445-ac01-44eee0776f17_annotated_false_size_900_quality_90_5a37e2403d21a2a517c6a8bcda63ec81dc6ec49c.jpg)
+*Axial graphic shows CNVII nuclei. The motor nucleus sends out its fibers to circle the CNVI nucleus before reaching the root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. The solitary tract nucleus receives taste information from the anterior 2/3 of the tongue.*
+
+![Axial graphic shows CNVII nuclei. The motor nucleus sends out its fibers to circle the CNVI nucleus before reaching the root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. The solitary tract nucleus receives taste information from the anterior 2/3 of the tongue.](images/app.statdx.com_image_thumbnail_1f7e56c2-da7a-4445-ac01-44eee0776f17_size_174_quality_85_0bbb0a3609041ca9802c7cd5aad00788b73befd0.jpg)
+*Axial graphic shows CNVII nuclei. The motor nucleus sends out its fibers to circle the CNVI nucleus before reaching the root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. The solitary tract nucleus receives taste information from the anterior 2/3 of the tongue.*
+
+![Sagittal graphic depicts CNVII within the temporal bone. Motor fibers pass through the temporal bone, dropping stapedius nerve to stapedius muscle, then exits via the stylomastoid foramen to the extracranial CNVII (entirely motor). Parasympathetic fibers from the superior salivatory nucleus reach the lacrimal gland via the greater superficial petrosal nerve and the submandibular-sublingual glands via the chorda tympanic nerve. The anterior 2/3 of tongue taste fibers come via the chorda tympani nerve.](images/app.statdx.com_image_thumbnail_4341ae03-74e3-4d1f-9c4a-64abc129d8e5_annotated_false_size_900_quality_90_bf108e48ca9b7f67d215d1919025f1cba3c4a01c.jpg)
+*Sagittal graphic depicts CNVII within the temporal bone. Motor fibers pass through the temporal bone, dropping stapedius nerve to stapedius muscle, then exits via the stylomastoid foramen to the extracranial CNVII (entirely motor). Parasympathetic fibers from the superior salivatory nucleus reach the lacrimal gland via the greater superficial petrosal nerve and the submandibular-sublingual glands via the chorda tympanic nerve. The anterior 2/3 of tongue taste fibers come via the chorda tympani nerve.*
+
+![Sagittal graphic depicts the extracranial motor branches of CNVII.](images/app.statdx.com_image_thumbnail_e0021355-6611-4f56-8626-1a996a69beab_annotated_false_size_900_quality_90_31edbab2a847c4fd473264b7ee391ef67e634654.jpg)
+*Sagittal graphic depicts the extracranial motor branches of CNVII.*
+
+
+### Axial Bone CT
+
+![First of 5 high-resolution NECT bone window images of the right temporal bone from superior to inferior demonstrates the CNVII canal for the labyrinthine segment coursing anterolaterally from the fundus of the internal auditory canal (IAC) to the geniculate fossa. The labyrinthine segment is the shortest and narrowest segment.](images/app.statdx.com_image_thumbnail_2614b2d3-b55a-4aa1-a9f0-cd42a559f89c_annotated_false_size_900_quality_90_88ea222236a17bbbc416b9c0627b4f069ce13c58.jpg)
+*First of 5 high-resolution NECT bone window images of the right temporal bone from superior to inferior demonstrates the CNVII canal for the labyrinthine segment coursing anterolaterally from the fundus of the internal auditory canal (IAC) to the geniculate fossa. The labyrinthine segment is the shortest and narrowest segment.*
+
+![This image demonstrates the geniculate fossa, which lodges the geniculate ganglion. The greater (superficial) petrosal nerve (not shown) arises here and travels anteromedially toward the foramen lacerum.](images/app.statdx.com_image_thumbnail_9dc82891-747d-47bc-9062-cf78add66d27_annotated_false_size_900_quality_90_c54445cb6723e911345cb453484a92597c124c6d.jpg)
+*This image demonstrates the geniculate fossa, which lodges the geniculate ganglion. The greater (superficial) petrosal nerve (not shown) arises here and travels anteromedially toward the foramen lacerum.*
+
+![This image demonstrates the tympanic segment of CNVII arising from the geniculate ganglion and traversing posteriorly and laterally to take a 2nd turn downward, forming the posterior genu (not shown).](images/app.statdx.com_image_thumbnail_5b120eb3-88ff-4e03-a54d-fa3a3016fc6e_annotated_false_size_900_quality_90_dbb06a58f941876786fd6a9ddce0f562c0e28180.jpg)
+*This image demonstrates the tympanic segment of CNVII arising from the geniculate ganglion and traversing posteriorly and laterally to take a 2nd turn downward, forming the posterior genu (not shown).*
+
+![This image demonstrates the high mastoid segment of CNVII canal posteriorly, which then descends toward the stylomastoid foramen. Nerve to stapedius arises at this level.](images/app.statdx.com_image_thumbnail_cb3686ca-c593-44c8-8d51-572fb1b629ec_annotated_false_size_900_quality_90_8cc7e4876e047fbb0be49448dd3f6e408f7eb6a6.jpg)
+*This image demonstrates the high mastoid segment of CNVII canal posteriorly, which then descends toward the stylomastoid foramen. Nerve to stapedius arises at this level.*
+
+![This image demonstrates the midmastoid segment of CNVII with adjacent chorda tympani.](images/app.statdx.com_image_thumbnail_1dcc808d-8d73-4184-8f08-21e43a2caba0_annotated_false_size_900_quality_90_a321fc73edfde94d6fe4d75099c5a3d4f0798786.jpg)
+*This image demonstrates the midmastoid segment of CNVII with adjacent chorda tympani.*
+
+![Axial soft tissue window NECT through the skull base demonstrates bilateral fat-containing stylomastoid foramen. CNVII exits from bone canal into the parotid space through this foramen.](images/app.statdx.com_image_thumbnail_7b3af725-cac2-4765-86b3-c545b89e05f5_annotated_false_size_900_quality_90_d589d93094f8ab7b461bdf635f84167518f26464.jpg)
+*Axial soft tissue window NECT through the skull base demonstrates bilateral fat-containing stylomastoid foramen. CNVII exits from bone canal into the parotid space through this foramen.*
+
+
+### Coronal Bone CT
+
+![First of 6 coronal reformatted high-resolution NECT bone window images show the labyrinthine segment of CNVII canal arising from the superior aspect of the fundus of the IAC.](images/app.statdx.com_image_thumbnail_d49b4c34-b40a-4ab0-8a44-3650489e34a4_annotated_false_size_900_quality_90_733a8b5c550b54c1ce8f78a5345d5fae63f2f200.jpg)
+*First of 6 coronal reformatted high-resolution NECT bone window images show the labyrinthine segment of CNVII canal arising from the superior aspect of the fundus of the IAC.*
+
+![This image shows the snake eye appearance of labyrinthine and tympanic segments coursing adjacent to each other. The labyrinthine segment courses posteriorly toward the geniculate fossa, and the tympanic segment courses anteriorly away from the geniculate fossa.](f2d68e77-4110-4249-82a9-cebb02924d7a)
+*This image shows the snake eye appearance of labyrinthine and tympanic segments coursing adjacent to each other. The labyrinthine segment courses posteriorly toward the geniculate fossa, and the tympanic segment courses anteriorly away from the geniculate fossa.*
+
+![This image shows the geniculate fossa, which lodges the geniculate ganglion.](77c33885-b679-445a-8fac-b3b5dabc5e64)
+*This image shows the geniculate fossa, which lodges the geniculate ganglion.*
+
+![This image shows the lateral semicircular canal, the tympanic segment of CNVII canal, and oval window from superior to inferior along the medial wall of the middle ear cavity.](2e039471-817e-469d-b709-a2678bf2ec7b)
+*This image shows the lateral semicircular canal, the tympanic segment of CNVII canal, and oval window from superior to inferior along the medial wall of the middle ear cavity.*
+
+![This image shows the descending mastoid segment of the CNVII canal. The chorda tympani leaves the CNVII canal 6 mm above the stylomastoid foramen and enters the middle ear cavity through the posterior canaliculus (not shown).](23b3c12a-9550-4427-b160-8d77a0bc02c9)
+*This image shows the descending mastoid segment of the CNVII canal. The chorda tympani leaves the CNVII canal 6 mm above the stylomastoid foramen and enters the middle ear cavity through the posterior canaliculus (not shown).*
+
+![This image shows the distal part of the CNVII mastoid segment exiting through the stylomastoid foramen into the parotid space.](c1adf4df-c9bc-4d93-a746-9745d2decd71)
+*This image shows the distal part of the CNVII mastoid segment exiting through the stylomastoid foramen into the parotid space.*
+
+
+### Axial T2 MR
+
+![First of 2 axial 3D T2 SPACE MR images through the left IAC shows CNVII arising from the lateral pontomedullary junction at the root exit zone. It then traverses the cerebellopontine angle cistern and enters the IAC through the porus acusticus. Note that posterior to it is the superior vestibular nerve.](a6cfef0e-4753-4453-b80d-17f32dd6eeed)
+*First of 2 axial 3D T2 SPACE MR images through the left IAC shows CNVII arising from the lateral pontomedullary junction at the root exit zone. It then traverses the cerebellopontine angle cistern and enters the IAC through the porus acusticus. Note that posterior to it is the superior vestibular nerve.*
+
+![This image shows the IAC and labyrinthine segments of CNVII in the anterosuperior quadrant.](ec5cf8b7-e0e8-4009-b74f-cbbe43ef4b63)
+*This image shows the IAC and labyrinthine segments of CNVII in the anterosuperior quadrant.*
+
+![Axial 3D T2 SPACE MR through the skull base at the level of stylomastoid foramina shows bilateral facial nerve mastoid segment exiting the bony canal and entering the parotid space. Note the fat surrounding the facial nerves bilaterally at this level.](45d635ea-5715-42cc-ae74-9911faed3498)
+*Axial 3D T2 SPACE MR through the skull base at the level of stylomastoid foramina shows bilateral facial nerve mastoid segment exiting the bony canal and entering the parotid space. Note the fat surrounding the facial nerves bilaterally at this level.*
+
+
+### Oblique Sagittal T2 MR
+
+![First of 3 sagittal oblique MR images of the IAC from medial to lateral is shown. This image through the porus acusticus shows the anteriorly traversing facial nerve trunk, and immediately posterior to it is the vestibulocochlear nerve, both entering the IAC.](13d10458-9884-4627-bd92-2eddc09cf8e8)
+*First of 3 sagittal oblique MR images of the IAC from medial to lateral is shown. This image through the porus acusticus shows the anteriorly traversing facial nerve trunk, and immediately posterior to it is the vestibulocochlear nerve, both entering the IAC.*
+
+![This image through the middle of the IAC shows the appearance of a ball in the catcher's mitt where the ball is CNVII and the catcher's mitt is formed by the vestibulocochlear nerve complex.](71f0b667-38f3-4457-81a4-d55b47221dce)
+*This image through the middle of the IAC shows the appearance of a ball in the catcher's mitt where the ball is CNVII and the catcher's mitt is formed by the vestibulocochlear nerve complex.*
+
+![This image through the fundus of the IAC shows CNVII in the anterosuperior quadrant above the crista falciformis. Note the anteroinferiorly located cochlear nerve, posterosuperiorly located superior vestibular nerve, and posteroinferiorly located inferior vestibular nerve.](3083a202-c7e5-438e-844d-26d1a8aa8a7e)
+*This image through the fundus of the IAC shows CNVII in the anterosuperior quadrant above the crista falciformis. Note the anteroinferiorly located cochlear nerve, posterosuperiorly located superior vestibular nerve, and posteroinferiorly located inferior vestibular nerve.*
+
+
+### Additional Images
+
+![First of 6 axial bone CT images of the left temporal bone presented from superior to inferior shows the labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolaterally over the top of the cochlea.](b642fe9c-849f-45cd-baeb-dd618d1c017c)
+*First of 6 axial bone CT images of the left temporal bone presented from superior to inferior shows the labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolaterally over the top of the cochlea.*
+
+![In this image, the labyrinthine segment of CNVII canal terminates in the geniculate fossa. The facial nerve canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from the geniculate fossa, coursing posterolaterally in axial plane, running under the lateral semicircular canal before turning 90 degrees inferiorly at the posterior genu to become the mastoid segment.](2203c0ca-aeba-48c4-b33e-c5a943eca9be)
+*In this image, the labyrinthine segment of CNVII canal terminates in the geniculate fossa. The facial nerve canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from the geniculate fossa, coursing posterolaterally in axial plane, running under the lateral semicircular canal before turning 90 degrees inferiorly at the posterior genu to become the mastoid segment.*
+
+![At the level of the oval window, the mastoid segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.](3f93bc54-7b77-41e5-a6eb-a3c09816bf03)
+*At the level of the oval window, the mastoid segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.*
+
+![Mastoid segment extends ~ 13 mm from the posterior genu to the stylomastoid foramen, coursing inferiorly within the posterior wall of the middle ear cavity. Mastoid segment is related anteriorly to the facial nerve recess and medially to the stapedius muscle within the pyramidal eminence on the posterior wall of the middle ear cavity.](4a4eb8ec-9a8d-4943-9fc7-9dfc25984f4a)
+*Mastoid segment extends ~ 13 mm from the posterior genu to the stylomastoid foramen, coursing inferiorly within the posterior wall of the middle ear cavity. Mastoid segment is related anteriorly to the facial nerve recess and medially to the stapedius muscle within the pyramidal eminence on the posterior wall of the middle ear cavity.*
+
+![At the level of the basal turn of the cochlea, the mastoid segment of the facial nerve is still visible. Both the nerve to stapedius muscle proximally and chorda tympani distally branch off the mastoid segment of CNVII.](d3ac2da4-1281-4b9d-86f2-03985fd1fc12)
+*At the level of the basal turn of the cochlea, the mastoid segment of the facial nerve is still visible. Both the nerve to stapedius muscle proximally and chorda tympani distally branch off the mastoid segment of CNVII.*
+
+![Image at the level of the stylomastoid foramen is shown. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.](92d1fbc4-d6e4-4f69-bbe5-c89725a4de55)
+*Image at the level of the stylomastoid foramen is shown. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.*
+
+![First of 6 coronal bone CT images of the left temporal bone presented from posterior to anterior shows the lower mastoid segment of CNVII and stylomastoid foramen.](ae24ed9e-1664-4042-b8ef-e0f30bbf7b04)
+*First of 6 coronal bone CT images of the left temporal bone presented from posterior to anterior shows the lower mastoid segment of CNVII and stylomastoid foramen.*
+
+![At the level of the round window, the posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is medial to the pyramidal eminence.](df93f5c7-2559-471a-b6b4-534913ff294e)
+*At the level of the round window, the posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is medial to the pyramidal eminence.*
+
+![At the level of the oval window, the tympanic segment of the facial nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients with oval window atresia, the facial nerve is found near or within the oval window niche.](5fe77a24-c199-4e0e-a523-fbaf029c1f06)
+*At the level of the oval window, the tympanic segment of the facial nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients with oval window atresia, the facial nerve is found near or within the oval window niche.*
+
+![At the level of the anterior margin of the oval window, the tympanic segment of CVII can be seen under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is now not seen. The facial nerve canal bony covering in this area is normally incomplete.](079fbe60-acad-40be-98b0-f94f6e976119)
+*At the level of the anterior margin of the oval window, the tympanic segment of CVII can be seen under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is now not seen. The facial nerve canal bony covering in this area is normally incomplete.*
+
+![In the anterior middle ear cavity, the labyrinthine segment of CNVII can be seen exiting the internal auditory canal over the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve.](a0c46779-ed2f-4e33-bd1d-fc865e0f3fff)
+*In the anterior middle ear cavity, the labyrinthine segment of CNVII can be seen exiting the internal auditory canal over the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve.*
+
+![In the most anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is seen within the geniculate fossa as an ovoid structure just above the cochlea.](514ba7ea-68b9-462e-a47b-05c3be058167)
+*In the most anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is seen within the geniculate fossa as an ovoid structure just above the cochlea.*
+
+![First of 2 axial high-resolution T2 MR images through the cerebellopontine angle cistern and internal auditory canal is shown. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it crosses through the cerebellopontine angle cistern.](b500bfe4-b150-430c-994d-7799886aa811)
+*First of 2 axial high-resolution T2 MR images through the cerebellopontine angle cistern and internal auditory canal is shown. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it crosses through the cerebellopontine angle cistern.*
+
+![Image through cephalad internal auditory canal on the patient's left shows the facial nerve anterior to the superior vestibular nerve throughout its internal auditory canal course.](37407bef-5f22-4533-8fd5-697657469ee6)
+*Image through cephalad internal auditory canal on the patient's left shows the facial nerve anterior to the superior vestibular nerve throughout its internal auditory canal course.*
+
+![Axial T1 MR at the level of the stylomastoid foramen shows the exiting low-signal facial nerve surrounded by high-signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this area is obscured.](b531a8a6-f92a-43a5-9d50-4a87165d35ef)
+*Axial T1 MR at the level of the stylomastoid foramen shows the exiting low-signal facial nerve surrounded by high-signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this area is obscured.*
+
+![First of 3 oblique sagittal T2 MR images presented from lateral to medial shows normal fundal anatomy. The horizontal crista falciformis separates the fundus into upper and lower portions. Facial nerve is anterosuperior, separated from superior vestibular nerve by a vertical bony septum called "Bill bar," which is not resolved. Below the falciform crest are the larger anterior cochlear nerve and posterior inferior vestibular nerve.](ae7999e8-8810-4529-a9be-dea532b8ba92)
+*First of 3 oblique sagittal T2 MR images presented from lateral to medial shows normal fundal anatomy. The horizontal crista falciformis separates the fundus into upper and lower portions. Facial nerve is anterosuperior, separated from superior vestibular nerve by a vertical bony septum called "Bill bar," which is not resolved. Below the falciform crest are the larger anterior cochlear nerve and posterior inferior vestibular nerve.*
+
+![In the mid internal auditory canal, 4 nerves are clearly identified. The facial nerve is anterosuperior.](6caa1ff2-053b-48d8-830f-dd5f39fd23dc)
+*In the mid internal auditory canal, 4 nerves are clearly identified. The facial nerve is anterosuperior.*
+
+![This image through the porus acusticus reveals the characteristic ball in catcher's mitt appearance of the facial and vestibulocochlear nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt."](42cd3bb6-d884-4d2d-909c-f5e2bbaeab52)
+*This image through the porus acusticus reveals the characteristic ball in catcher's mitt appearance of the facial and vestibulocochlear nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt."*
+

docs_md/articles/defect-in-abdominal-wall-hernia_5af046fa-59ef-45b5-952b-acbcdee36196.md

@@ -0,0 +1,228 @@
+---
+title: "Defect in Abdominal Wall (Hernia)"
+docid: "5af046fa-59ef-45b5-952b-acbcdee36196"
+authors:
+  - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+    value: "Siva P. Raman, MD"
+breadcrumbs:
+  -
+    name: "Gastrointestinal"
+    slug: "gastrointestinal"
+    treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+  -
+    name: "Differential Diagnosis"
+    slug: "differential-diagnosis"
+    treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+  -
+    name: "Abdominal Wall"
+    slug: "abdominal-wall"
+    treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+  -
+    name: "Anatomically Based Differentials"
+    slug: "anatomically-based-differentials"
+    treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+  -
+    name: "Defect in Abdominal Wall (Hernia)"
+    slug: "defect-in-abdominal-wall-hernia"
+    treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "284df942-e3e0-4957-8c3b-8b7855e23af9"
+imageCount: 16
+lastUpdated: "07/01/22"
+pageDescription: "Defect in Abdominal Wall (Hernia)"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Defect in Abdominal Wall (Hernia)"
+pageTitle: "Defect in Abdominal Wall (Hernia) | STATdx"
+enhancedTitle: "Defect in Abdominal Wall (Hernia)"
+type: "DDX"
+references: true
+breadcrumbs:
+  - "Gastrointestinal"
+  - "Differential Diagnosis"
+  - "Abdominal Wall"
+  - "Anatomically Based Differentials"
+  - "Defect in Abdominal Wall (Hernia)"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+  
+  
+    - CT is most accurate imaging modality for diagnosis of hernias and associated complications
+    - US can be helpful for determining reducibility of hernias, as well as diagnosis of hernias, which are transiently reducible
+          - Offers advantage of scanning patient in upright position or with Valsalva maneuver to elicit hernia
+          - Efficacy of US for hernias is debatable in literature, and CT should certainly be 1st-line modality in patients with acute presentation or concerns for hernia-related complications
+                  - US should be reserved for nonurgent presentation in outpatient setting
+    - Evaluate any hernia for presence of complications, including bowel involvement, obstruction, and ischemia
+          - Different types of hernias are associated with very different risks of complications
+    - Descriptive terms used to describe abdominal wall hernias
+          - **Interparietal** (i.e., interstitial) hernia: Hernia sac is located in fascial planes between abdominal wall muscles without entering subcutaneous soft tissues
+          - **Richter** hernia: Entirety of bowel circumference does not herniate (just antimesenteric border of bowel)
+- ## Helpful Clues for Common Diagnoses
+  
+  
+    - **Inguinal Hernia**
+          - Most common type of external hernia (~ 80%) with indirect hernias typically congenital (due to weakness of processus vaginalis), and direct hernias usually acquired due to abdominal wall weakness
+                  - Hernia seen in groin region anterior to horizontal plane of pubic tubercle
+                  - Do not result in compression of femoral vessels (unlike femoral hernia)
+          - **Direct** hernias: Hernia sac arises anteromedial to inferior epigastric vessels
+          - **Indirect** hernia: Hernia sac arises superomedial to inferior epigastric vessels
+                  - 5x more common than direct hernias
+                  - Complications more common with indirect hernias
+    - **Femoral Hernia**
+          - Most commonly seen in older female patients (especially > 80 years) but much less common than inguinal hernias
+          - Hernia extends into femoral canal medial to femoral vein and inferior to inferior epigastric vessels with frequent compression of femoral vein
+          - Hernia sac located posterior and lateral to pubic tubercle
+          - Very high risk of complications (incarceration, strangulation) and mortality compared to inguinal hernias
+    - **Ventral Hernia**
+          - General term encompassing hernias extending through anterior and lateral abdominal wall
+                  - Can be acquired or congenital
+          - **Epigastric** hernias occur at midline through linea alba above umbilicus, while **hypogastric** hernias occur at midline below umbilicus
+          - **Incisional** hernias occur through any prior surgical incision site
+                  - Most often occur within a few months (usually first 4 months) of surgery but can occur at later time points as well
+                  - **Parastomal hernias**(considered type of incisional hernia) are quite common adjacent to ileostomy or colostomy
+                            - Parastomal hernias tend to slowly develop and enlarge over time and are very common with end-colostomies (48%) and end-ileostomies (28%) but much less common with loop ileostomies (6%)
+          - Even if asymptomatic, most ventral hernias get larger over time with increasing risk of complications, making surgical treatment advisable
+    - **Spigelian Hernia**
+          - Hernia extending through defect in aponeurosis of internal oblique and transverse abdominal muscles
+          - Arise along lateral margin of rectus abdominis muscles, at level of arcuate line, inferior and lateral to umbilicus
+          - Usually congenital in children and acquired in adults (prior surgery, obesity, pregnancies, etc. are risk factors)
+          - High risk of strangulation and incarceration
+    - **Lumbar Hernia**
+          - Hernia extends through defect in lumbar muscle or thoracolumbar fascia (usually below 12th rib and above iliac crest)
+                  - Can herniate through superior (Grynfeltt-Lesshaft) or inferior (petit) lumbar triangles
+          - Most (80%) are acquired, usually due to surgical incisions (especially renal surgery)
+          - Complications uncommon due to typically large neck, which makes incarceration/strangulation uncommon
+    - **Umbilical Hernia**
+          - Hernia at midline extends through umbilical ring (usually upper 1/2 of umbilicus)
+          - Can be congenital (diagnosed in infancy) or acquired (usually in middle age)
+                  - Congenital type 8x more common in Black patients but most resolve spontaneously by 4-6 years of age
+                  - Acquired hernias associated with obesity, multiparity, and ascites
+          - Very common and usually small/asymptomatic, but larger or symptomatic hernias may require repair
+    - **Subcutaneous Abdominal Wall Mass (Mimic)**
+          - Any subcutaneous or intramuscular mass may be superficially mistaken for hernia on clinical examination, although distinction should be obvious on imaging
+          - Consider inguinal lymphadenopathy, abdominal wall tumors, cryptorchidism (especially in children), abscess, hydrocele, varicocele, or hematoma as entities that may be mistaken for hernia on physical examination
+    - **Enterocutaneous Fistula (Mimic)**
+          - Gas- or contrast-filled tract from intraabdominal bowel loop into anterior abdominal wall may be confused for hernia
+                  - Bowel loops often tethered to anterior abdominal wall at site of fistula
+          - Careful examination illustrates lack of true abdominal wall defect
+- ## Helpful Clues for Less Common Diagnoses
+  
+  
+    - **Obturator Hernia**
+          - Rare type of hernia extending through obturator foramen into superolateral obturator canal
+                  - Usually involves loop of ileum but can involve any pelvic viscera
+          - Typically seen in older female patients (especially older or multiparous females) secondary to either pelvic floor defect or pelvic floor laxity
+          - High risk of complications (incarceration, strangulation) and mortality
+    - **Traumatic Abdominal Wall Hernia**
+          - Hernia in anterior abdominal wall developing at site of focal trauma
+          - Majority occur in lower abdomen with iliac crest region very common due to seat belt injuries
+          - Most commonly seen in young children < 10 years due to bicycle injury (e.g., handlebar hernia) but can also be seen in adults after high-energy trauma (e.g., motor vehicle collisions)
+    - **Sciatic Hernia**
+          - Very uncommon hernia involving herniation of bowel loop through greater sciatic foramen laterally into subgluteal region
+          - Occurs most often in female patients, likely as result of piriformis muscle atrophy
+          - Can result in symptoms of sciatica as result of compression of sciatic nerve
+    - **Perineal Hernia**
+          - Uncommon hernia with hernia sac extending anteriorly through urogenital diaphragm (most common) or posteriorly between levator ani and coccygeus muscles
+          - Usually diagnosed in older women (> 50 years of age) with history of prior surgery in deep pelvis/perineum, prior pregnancies, obesity, or ascites
+    - **Spermatic Cord Lipoma or Liposarcoma (Mimic)**
+          - Uncommon fat-containing mass arising in spermatic cord, which can extend into scrotum inferiorly or inguinal canal/retroperitoneum superiorly
+          - When extending into inguinal canal, can mimic inguinal hernia, but lesion typically appears expansile and mass-like
+          - Liposarcomas will often demonstrate internal complexity (or even soft tissue component) depending on degree of dedifferentiation
+                  - Well-differentiated liposarcomas may appear largely fat attenuation and are more apt to be confused for inguinal hernia containing omental fat
+                  - Usually appear hyperechoic on US (particularly when well differentiated) with similar echogenicity to subcutaneous fat
+
+## References
+
+# Selected References
+
+1. [Aly M et al: Should surgeons repair symptomatic, clinically occult, radiologically evident, inguinal hernias? A case-control study of patient-reported outcomes. Hernia. 25(5):1209-13, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33428011%5Bpmid%5D)
+1. [Fezoulidi G et al: Amyand's hernia: presumptive diagnosis by CT and literature review. Radiol Case Rep. 16(4):911-5, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33613803%5Bpmid%5D)
+1. [Ng M et al: Paratesticular liposarcoma: a rare cause of scrotal lump. BMJ Case Rep. 14(2):e240008, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33568414%5Bpmid%5D)
+1. [Steenburg SD et al: Traumatic abdominal wall injuries-a primer for radiologists. Emerg Radiol. 28(2):361-71, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=32827286%5Bpmid%5D)
+1. [Kim AG et al: Inguinal and other hernias. Adv Pediatr. 67:131-43, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32591057%5Bpmid%5D)
+1. [Park J: Obturator hernia: clinical analysis of 11 patients and review of the literature. Medicine (Baltimore). 99(34):e21701, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32846788%5Bpmid%5D)
+1. [Keenan RA et al: Paratesticular sarcomas: a case series and literature review. Ther Adv Urol. 11:1756287218818029, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30671140%5Bpmid%5D)
+1. [Mnari W et al: Strangulated obturator hernia: a case report with literature review. Pan Afr Med J. 32:144, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31303916%5Bpmid%5D)
+1. [Tonolini M: A closer look at the stoma: multimodal imaging of patients with ileostomies and colostomies. Insights Imaging. 10(1):41, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30927144%5Bpmid%5D)
+1. [Park HR et al: Sonographic evaluation of inguinal lesions. Clin Imaging. 40(5):949-55, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27209238%5Bpmid%5D)
+1. [Stensby JD et al: Athletic injuries of the lateral abdominal wall: review of anatomy and MR imaging appearance. Skeletal Radiol. 45(2):155-62, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26450606%5Bpmid%5D)
+1. [Valeshabad AK et al: An important mimic of inguinal hernia. Urology. 97:e11, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27502033%5Bpmid%5D)
+1. [Burkhardt JH et al: Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 31(2):E1-12, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21415178%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![Axial CECT shows a large right inguinal hernia <img src='img/arrows/WS.png'/> containing multiple loops of small bowel without evidence of obstruction. Inguinal hernias account for the vast majority of external hernias.](images/app.statdx.com_image_thumbnail_3583367b-c798-433a-97ec-20c5a8439f86_annotated_true_size_900_quality_90_0948a1fef0de4912e5097b26f8537c0e26d4fc92.jpg)
+**Inguinal Hernia**
+*Axial CECT shows a large right inguinal hernia <img src='img/arrows/WS.png'/> containing multiple loops of small bowel without evidence of obstruction. Inguinal hernias account for the vast majority of external hernias.*
+
+![Axial CECT shows a large right inguinal hernia <img src='img/arrows/WS.png'/> containing multiple loops of small bowel without evidence of obstruction. Inguinal hernias account for the vast majority of external hernias.](images/app.statdx.com_image_thumbnail_3583367b-c798-433a-97ec-20c5a8439f86_size_174_quality_85_82a7a4b19be0fdd03147e6497138a5ed318471a7.jpg)
+**Inguinal Hernia**
+*Axial CECT shows a large right inguinal hernia <img src='img/arrows/WS.png'/> containing multiple loops of small bowel without evidence of obstruction. Inguinal hernias account for the vast majority of external hernias.*
+
+![Coronal NECT shows a classic right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of small bowel <img src='img/arrows/WC.png'/> without evidence of obstruction.](images/app.statdx.com_image_thumbnail_eb4d3e58-8633-4409-9ae5-aee00cfcf14b_annotated_true_size_900_quality_90_7969860455531a5a49e1796b5546a0955ecebff5.jpg)
+**Inguinal Hernia**
+*Coronal NECT shows a classic right inguinal hernia <img src='img/arrows/WS.png'/> containing loops of small bowel <img src='img/arrows/WC.png'/> without evidence of obstruction.*
+
+![Axial CECT shows a herniated bowel loop <img src='img/arrows/WS.png'/> in the left groin. Note the close relationship of the hernia to the femoral vessels at the level of the symphysis pubis, characteristic of a femoral hernia.](images/app.statdx.com_image_thumbnail_cbb6be6d-ef60-4c59-8381-050546a2abeb_annotated_true_size_900_quality_90_2262735aae80cb7b95942c25a824cfd762c8edd0.jpg)
+**Femoral Hernia**
+*Axial CECT shows a herniated bowel loop <img src='img/arrows/WS.png'/> in the left groin. Note the close relationship of the hernia to the femoral vessels at the level of the symphysis pubis, characteristic of a femoral hernia.*
+
+![Sagittal volume-rendered CECT shows a ventral hernia containing loops of small bowel <img src='img/arrows/WS.png'/>. The small bowel proximal to the hernia sac is dilated <img src='img/arrows/WC.png'/>, compatible with small bowel obstruction.](images/app.statdx.com_image_thumbnail_7ffd9022-789c-42bd-b223-d1b4d6e554f1_annotated_true_size_900_quality_90_9391f441d54fe2fab101abd3a0187d208090c734.jpg)
+**Ventral Hernia**
+*Sagittal volume-rendered CECT shows a ventral hernia containing loops of small bowel <img src='img/arrows/WS.png'/>. The small bowel proximal to the hernia sac is dilated <img src='img/arrows/WC.png'/>, compatible with small bowel obstruction.*
+
+![Axial CECT in a patient with a history of prior thoracic surgery shows a fat-containing ventral hernia <img src='img/arrows/WS.png'/> arising in the upper abdomen. Ventral hernias occurring above the umbilicus, as in this case, are termed epigastric hernias.](images/app.statdx.com_image_thumbnail_5dd4e9d7-2e6d-43cf-baab-b1545d2834af_annotated_true_size_900_quality_90_a4faa66c81b227f46da88a8b9fc866e9f2cfbd95.jpg)
+**Ventral Hernia**
+*Axial CECT in a patient with a history of prior thoracic surgery shows a fat-containing ventral hernia <img src='img/arrows/WS.png'/> arising in the upper abdomen. Ventral hernias occurring above the umbilicus, as in this case, are termed epigastric hernias.*
+
+![Axial CECT shows a left abdominal spigelian hernia <img src='img/arrows/WS.png'/> with multiple dilated loops of small bowel <img src='img/arrows/WC.png'/>, compatible with small bowel obstruction.](images/app.statdx.com_image_thumbnail_d74d0103-b3f6-4ad4-8b34-1b44b388214f_annotated_true_size_900_quality_90_bb2768cbce25f6aa0c01e47e19e2ce2cf18d5bf8.jpg)
+**Spigelian Hernia**
+*Axial CECT shows a left abdominal spigelian hernia <img src='img/arrows/WS.png'/> with multiple dilated loops of small bowel <img src='img/arrows/WC.png'/>, compatible with small bowel obstruction.*
+
+![Axial NECT shows a large lumbar hernia <img src='img/arrows/WS.png'/> in the right flank containing a portion of the right kidney <img src='img/arrows/WC.png'/>.](images/app.statdx.com_image_thumbnail_1708fe45-dfcb-410a-8c90-14621c81b27b_annotated_true_size_900_quality_90_f588511b4140e0b5c6b28e0b163c550560b55e22.jpg)
+**Lumbar Hernia**
+*Axial NECT shows a large lumbar hernia <img src='img/arrows/WS.png'/> in the right flank containing a portion of the right kidney <img src='img/arrows/WC.png'/>.*
+
+![Coronal CECT shows a large lumbar hernia containing colon <img src='img/arrows/WS.png'/>, small bowel <img src='img/arrows/WO.png'/>, as well as a portion of the right hepatic lobe <img src='img/arrows/WC.png'/>. Lumbar hernias are often secondary to prior surgical incisions and are particularly common after renal surgeries.](8846334e-e8af-4d7b-aee2-abb493d1b4a0)
+**Lumbar Hernia**
+*Coronal CECT shows a large lumbar hernia containing colon <img src='img/arrows/WS.png'/>, small bowel <img src='img/arrows/WO.png'/>, as well as a portion of the right hepatic lobe <img src='img/arrows/WC.png'/>. Lumbar hernias are often secondary to prior surgical incisions and are particularly common after renal surgeries.*
+
+![Sagittal CECT shows an umbilical hernia containing ascites <img src='img/arrows/WC.png'/> in a patient with cirrhosis and portal hypertension.](3d150139-0c6b-4425-b159-4ecede4fd324)
+**Umbilical Hernia**
+*Sagittal CECT shows an umbilical hernia containing ascites <img src='img/arrows/WC.png'/> in a patient with cirrhosis and portal hypertension.*
+
+![Axial CECT shows an enterocutaneous fistula with enteric contrast directly extending from the small bowel into the anterior abdominal wall <img src='img/arrows/WS.png'/>.](bb6e2124-d143-4d1f-aa40-2385883b9279)
+**Enterocutaneous Fistula (Mimic)**
+*Axial CECT shows an enterocutaneous fistula with enteric contrast directly extending from the small bowel into the anterior abdominal wall <img src='img/arrows/WS.png'/>.*
+
+![Axial CECT shows a loop of small bowel <img src='img/arrows/WC.png'/> lying between the obturator externus and pectineus muscles, compatible with an obturator hernia.](f6e92a2e-7ae0-49a3-bd09-af98daeda5fb)
+**Obturator Hernia**
+*Axial CECT shows a loop of small bowel <img src='img/arrows/WC.png'/> lying between the obturator externus and pectineus muscles, compatible with an obturator hernia.*
+
+![Axial CECT in a trauma patient shows disruption of the musculofascial plane <img src='img/arrows/WO.png'/> near the insertion into the iliac crest and thoracolumbar fascia. Note the presence of adjacent subcutaneous hematoma. The spleen was also lacerated (not shown). These findings are compatible with a traumatic hernia.](580fe71b-0f2b-4eb1-9a73-4de7858abd85)
+**Traumatic Abdominal Wall Hernia**
+*Axial CECT in a trauma patient shows disruption of the musculofascial plane <img src='img/arrows/WO.png'/> near the insertion into the iliac crest and thoracolumbar fascia. Note the presence of adjacent subcutaneous hematoma. The spleen was also lacerated (not shown). These findings are compatible with a traumatic hernia.*
+
+![Axial T1 MR shows a large mass with fat signal <img src='img/arrows/WS.png'/> extending through the inguinal canal into the left scrotum. This was found to be a spermatic cord liposarcoma at resection.](4aac9712-88a8-4394-8177-0461d0ebe6be)
+**Spermatic Cord Lipoma or Liposarcoma (Mimic)**
+*Axial T1 MR shows a large mass with fat signal <img src='img/arrows/WS.png'/> extending through the inguinal canal into the left scrotum. This was found to be a spermatic cord liposarcoma at resection.*
+
+![Sagittal US in the same patient shows that the mass <img src='img/arrows/WS.png'/> is very echogenic as a result of its fatty component, a fairly common appearance for these lesions, and extends down to just above the testicle <img src='img/arrows/WC.png'/>.](3a9cd923-24be-4513-aea3-737eb8011503)
+**Spermatic Cord Lipoma or Liposarcoma (Mimic)**
+*Sagittal US in the same patient shows that the mass <img src='img/arrows/WS.png'/> is very echogenic as a result of its fatty component, a fairly common appearance for these lesions, and extends down to just above the testicle <img src='img/arrows/WC.png'/>.*
+
+
+### Additional Images
+
+![Axial CECT shows a loculated fluid collection <img src='img/arrows/WS.png'/> in the subcutaneous tissue adjacent to the site of incisional hernia repair <img src='img/arrows/WC.png'/>  (abdominal wall abscess).](90bb3322-868c-4f01-ab71-aa841a8ebe2b)
+**Subcutaneous Abscess (Mimic)**
+*Axial CECT shows a loculated fluid collection <img src='img/arrows/WS.png'/> in the subcutaneous tissue adjacent to the site of incisional hernia repair <img src='img/arrows/WC.png'/>  (abdominal wall abscess).*
+
+![Axial CECT shows a partly calcified mass <img src='img/arrows/WS.png'/> in the abdominal wall adjacent to a descending colostomy (metastatic colonic carcinoma).](7b6501cd-86b1-4f54-a4ec-8ec1bf889436)
+**Soft Tissue Neoplasm (Mimic)**
+*Axial CECT shows a partly calcified mass <img src='img/arrows/WS.png'/> in the abdominal wall adjacent to a descending colostomy (metastatic colonic carcinoma).*
+

docs_md/articles/desmoid_f0ca3968-a2f3-4f1d-8825-44819a047224.md

@@ -0,0 +1,451 @@
+---
+title: "Desmoid"
+docid: "f0ca3968-a2f3-4f1d-8825-44819a047224"
+authors:
+  - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+    value: "Siva P. Raman, MD"
+breadcrumbs:
+  -
+    name: "Gastrointestinal"
+    slug: "gastrointestinal"
+    treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+  -
+    name: "Diagnosis"
+    slug: "diagnosis"
+    treeNodeId: "5a7c51af-b1c6-4629-8f0e-d99e6fe57a98"
+  -
+    name: "Peritoneum, Mesentery, and Abdominal Wall"
+    slug: "peritoneum-mesentery-and-abdominal-"
+    treeNodeId: "a3fb9f00-f894-4b38-9e01-2f78406cf547"
+  -
+    name: "Benign Neoplasms"
+    slug: "benign-neoplasms"
+    treeNodeId: "6e8371e6-baeb-49ad-b087-cf827ae9f3a0"
+  -
+    name: "Desmoid"
+    slug: "desmoid"
+    treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "816f437b-64d7-47e7-b5de-186fedf4daf6"
+imageCount: 32
+lastUpdated: "06/11/25"
+pageDescription: "Desmoid"
+pageKeywords: "Gastrointestinal, Diagnosis, Peritoneum, Mesentery, and Abdominal Wall, Benign Neoplasms, Desmoid"
+pageTitle: "Desmoid | STATdx"
+enhancedTitle: "Desmoid"
+type: "DX"
+references: true
+breadcrumbs:
+  - "Gastrointestinal"
+  - "Diagnosis"
+  - "Peritoneum, Mesentery, and Abdominal Wall"
+  - "Benign Neoplasms"
+  - "Desmoid"
+---
+# KEY FACTS
+
+- ## Terminology
+  
+  
+    - Rare, benign, locally aggressive, nonencapsulated mesenchymal neoplasms of connective or fibrous tissue
+- ## Imaging
+  
+  
+    - Can be intraabdominal (particularly small bowel mesentery) or extraabdominal (including abdominal wall)
+          - When involving abdominal wall, often involve rectus or oblique muscles, frequently at incision sites
+    - Usually solid with well-defined margins, but can also be infiltrative in appearance
+    - Classically thought to be low signal on all MR pulse sequences due to fibrous content, but this is unreliable
+    - Usually hyperdense to muscle on NECT and hypoenhancing on CECT (but rarely avidly enhancing)
+- ## Pathology
+  
+  
+    - Strong associations with Gardner syndrome and familial adenomatous polyposis (FAP)
+    - Other major risk factors include previous abdominal surgery (75% of cases), trauma, pregnancy, or oral contraceptives
+- ## Clinical Issues
+  
+  
+    - Complications arise from locally aggressive growth with involvement of adjacent structures, such as small bowel obstruction, ureteral obstruction, bladder outlet obstruction, hydrosalpinx, etc.
+    - Surgical resection was once mainstay of treatment, but this has now become increasingly controversial due to morbidity and mortality of resection, as well as high risk of recurrence (even in setting of R0 resection)
+    - Active surveillance now mainstay of treatment whenever possible (particularly when lesions are small and asymptomatic), as many lesions remain stable or even spontaneously regress
+    - Conservative management with variety of pharmacologic agents and radiation treatment increasingly utilized even for symptomatic lesions
+
+# TERMINOLOGY
+
+- ## Synonyms
+  
+  
+    - Deep or aggressive fibromatosis
+- ## Definitions
+  
+  
+    - Rare, benign, locally aggressive, nonencapsulated mesenchymal neoplasms of connective or fibrous tissue
+
+# IMAGING
+
+- ## General Features
+  
+  
+    - ### Best diagnostic clue
+      
+      
+          - Small bowel mesentery or abdominal wall mass arising at site of scarring from prior surgery
+    - ### Location
+      
+      
+          - Can be intraabdominal or extraabdominal (including abdominal wall)
+                  - **Abdominal desmoids**
+                            - Account for 2/3 of all desmoid tumors
+                            - Tumors associated with Gardner syndrome or familial adenomatous polyposis (FAP) are usually intraabdominal
+                            - Most commonly occur in small bowel mesentery but can occur nearly anywhere
+                  - **Extraabdominal**
+                            - Pregnancy-related desmoid tumors tend to occur within abdominal wall
+                            - 1/3 occur in shoulder and upper extremity
+                            - ~ 20% in chest wall, ~ 10% in head and neck
+                            - Musculature most often involved: Rectus, internal/external oblique, psoas, pelvic (rare)
+    - ### Morphology
+      
+      
+          - Most often demonstrate clear, lobulated margins on imaging (75%), but minority of cases can appear ill defined and infiltrative (25%)
+    - **Key concepts**
+          - Locally aggressive primary mesenchymal tumor
+                  - Sometimes classified as low-grade fibrosarcoma or subgroup of fibromatosis
+                  - Tend to arise in musculoaponeurotic planes
+                  - Tend to invade locally, recur after treatment, and grow very rapidly, especially in Gardner syndrome
+                  - May involve bowel loops, bladder, ribs, pelvic bones, and virtually any other structure
+                  - Lesions are locally aggressive and cause morbidity/mortality primarily due to local invasion, but **do not metastasize**
+          - Desmoids can be solitary or multiple (15% of cases)
+          - Etiology
+                  - Most cases are sporadic
+                  - 75% of patients with desmoid tumors have had prior abdominal surgery
+                  - May be associated with Gardner syndrome and FAP, which can be characterized by a number of abnormalities
+                            - Familial polyposis coli, osteomas, dental defects, congenital pigmented lesions of retina
+                            - Epidermoid (sebaceous) cyst and fibromas of skin
+                            - Periampullary, adrenal, thyroid, and liver malignancies
+                            - 18-20% of patients with Gardner syndrome develop desmoids and desmoids account for 45% of fibrous lesions in Gardner syndrome
+- ## CT Findings
+  
+  
+    - **Abdominal wall desmoids**
+          - Usually solid with well-defined margins (but can be infiltrative in appearance)
+          - Usually hyperdense compared to surrounding muscle on NECT
+          - Usually hypoenhancing on CECT, but can in some cases be quite avidly enhancing
+          - Often involve rectus or oblique muscles and occur frequently at incision sites
+    - **Mesenteric desmoids**
+          - Soft tissue mass with well-defined or ill-defined margins
+          - Hyperdense relative to muscle on NECT with variable, heterogeneous enhancement on CECT
+          - Whorled appearance: Radiating fibrotic strands into adjacent mesenteric fat
+          - May displace, retract, or compress adjacent bowel loops and potentially cause small bowel obstruction
+          - Can infiltrate into adjacent organs and musculature
+          - Calcification very uncommon
+- ## MR Findings
+  
+  
+    - Can be poorly marginated or very well circumscribed
+          - Often will cross fascial boundaries (1/3 of cases) and may be lobulated or infiltrative
+    - Classically thought to be low signal on all pulse sequences due to fibrous content
+          - Not consistent or common feature, and may be seen with other entities (including malignancies, such as fibrosarcoma and malignant fibrous histiocytoma)
+          - Usually homogeneously isointense or mildly hypointense on T1WI
+          - Can demonstrate T2 hypointensity due to fibrotic component, but in practice more often heterogeneously high signal on T2WI 
+                  - Higher T2 signal more common with actively growing or aggressive desmoids
+          - Internal bands of low signal on all pulse sequences (corresponding to fibrosis and collagen) in 2/3 of cases
+          - Variable enhancement on post gadolinium sequences, but usually heterogeneous
+    - No specific MR features to differentiate desmoids from malignancy or to make specific imaging diagnosis
+- ## Ultrasonographic Findings
+  
+  
+    - Well-defined mesenteric mass with variable echogenicity
+- ## Radiographic Findings
+  
+  
+    - Fluoroscopic double-contrast studies
+          - FAP: Innumerable, variably sized radiolucent filling defects in colon
+- ## Imaging Recommendations
+  
+  
+    - ### Best imaging tool
+      
+      
+          - Multiplanar CT or MR
+
+# DIFFERENTIAL DIAGNOSIS
+
+- ## Soft Tissue Sarcoma
+  
+  
+    - Imaging cannot differentiate desmoid tumor in abdominal wall or musculature from sarcoma and biopsy ultimately required to make this distinction
+    - History of prior surgical incision at site of mass raises possibility of desmoid rather than malignancy
+- [Leukemia and Lymphoma](/document/leukemia-and-lymphoma-abdominal-si-/b763f036-e025-4f6d-8ae3-8af4257c5617)
+    - Retroperitoneal and mesenteric lymphadenopathy, which is typically much softer than desmoid (envelops, but rarely obstructs, bowel or vessels)
+- [Omental or Mesenteric Metastases](/document/peritoneal-metastases/77ce2f66-499b-4e2e-b361-4a9919313970)
+    - Usually multiple less well-defined lesions that are often associated with stranding and induration in mesentery and omentum
+- [Carcinoid Tumor](/document/carcinoid-tumor/ae665f80-1b75-4726-9396-18c06259bb78)
+    - Usually occurs in right lower quadrant ileocolic mesentery
+    - Desmoplastic reaction and calcification very common, features which are not typically found in desmoids
+- ## Small Bowel Tumors Extending Into Mesentery
+  
+  
+    - Gastrointestinal stromal tumors (GISTs) or small bowel adenocarcinoma can extend into mesentery and appear similar to desmoid tumor
+- [Abdominal Mesothelioma](/document/abdominal-mesothelioma/a2c0e285-e04b-4889-8cdf-ace038613aa6)
+    - Arises from serosal lining of pleural and peritoneal cavity
+    - Mostly affects males exposed to asbestos
+    - Peritoneal cavity is involved alone or in association with pleural disease
+    - Usually diffusely thickens omentum and mesentery ± peritoneal and omental nodular masses, ascites
+- [Sclerosing Mesenteritis](/document/sclerosing-mesenteritis/39256300-bb6c-4dad-ba7e-3a6ccf5c38c2)
+    - Usually less mass-like than desmoid, although retractile mesenteritis can produce discrete mesenteric mass with desmoplastic reaction and calcification
+
+# PATHOLOGY
+
+- ## General Features
+  
+  
+    - ### Etiology
+      
+      
+          - Exact cause is unknown
+          - Majority of cases are sporadic
+          - Strong associations with Gardner syndrome and FAP
+                  - Due to mutation in *APC* gene (5q22)
+                  - Autosomal dominant disorder characterized by innumerable colonic polyps and multiple extracolonic tumors (including desmoids in 18-20% of cases)
+          - Other risk factors include previous abdominal surgery (75% of cases), trauma, pregnancy, or oral contraceptives
+          - Most often in women of childbearing age
+- ## Staging, Grading, & Classification
+  
+  
+    - Church et al staging system for desmoid tumors (primarily intended for FAP-related desmoids)
+          - Stage I: Asymptomatic patients with tumors < 10 cm that are not growing
+          - Stage II: Mildly symptomatic patients with tumors < 10 cm that are not growing
+          - Stage III: Moderately symptomatic, bowel/ureter obstruction, tumors 10-20 cm, or tumor slowly growing
+          - Stage IV: Severely symptomatic, septic complications (such as abscess/fistula), tumor > 20 cm, or tumor rapidly growing
+          - Staging system can be used to guide treatment, with stage I and II desmoids potentially treated with active surveillance (along with low toxicity drugs), while stage III and IV desmoids often treated with surgical resection and more aggressive pharmacologic treatment
+- ## Gross Pathologic & Surgical Features
+  
+  
+    - Desmoid tumors may be intermediate step between reparative process and true malignancy
+    - Tan/white, firm, well- or poorly defined mass
+    - May be "rock hard" and resistant to percutaneous biopsy
+- ## Microscopic Features
+  
+  
+    - Well-differentiated fibroblasts invading surrounding tissues
+    - Elongated spindle-shaped cells of uniform appearance with dense bands of collagen
+
+# CLINICAL ISSUES
+
+- ## Presentation
+  
+  
+    - ### Most common signs/symptoms
+      
+      
+          - Patients may be asymptomatic or may present with abdominal pain and palpable mass
+          - Acute abdominal findings
+                  - Due to ischemia/ulceration of mass
+                  - Encasement of mesentery and bowel → ischemia and obstruction → progressive resection of bowel → short gut syndrome
+                  - Hydronephrosis due to ureteral encasement
+- ## Demographics
+  
+  
+    - ### Age
+      
+      
+          - 70% of cases between 20-40 years old
+          - Tends to be more aggressive in younger patients
+    - ### Sex
+      
+      
+          - M:F = 1:3
+          - Increased incidence in women of childbearing age
+    - ### Epidemiology
+      
+      
+          - Rare: 2-4 cases per million per year
+          - 18-20% of patients with Gardner syndrome develop desmoid tumor
+                  - Mesenteric location more common than abdominal wall desmoid
+          - 8-18% of desmoids are related to pregnancy, typically develop in 3rd trimester or post partum, and are most often located in abdominal wall
+- ## Natural History & Prognosis
+  
+  
+    - Complications
+          - Locally aggressive growth pattern with compression and invasion of adjacent structures
+                  - Intraabdominal desmoids tend to be most aggressive and infiltrative (particularly when associated with FAP or Gardner syndrome)
+                  - Can cause bowel obstruction, ureteral obstruction, and bowel ischemia due to vasculature encasement
+                  - In pelvis, can cause bladder outlet obstruction or involve fallopian tubes and cause hydrosalpinx
+                  - Extraabdominal desmoids can involve nerves and cause pain
+                  - Chest wall desmoids can invade pleura
+          - Short gut syndrome can be major issue after multiple small bowel resections
+          - High recurrence rate (up to 2/3 of cases)
+                  - Imaging and pathology not predictive of recurrence
+    - Poor prognostic features
+          - Large size of tumor ( > 10 cm) and multiplicity
+          - Extensive involvement of bowel loops, encasement of mesenteric vessels, and involvement of ureters
+- ## Treatment
+  
+  
+    - Active surveillance now considered 1st-line treatment whenever possible, and National Comprehensive Cancer Network (NCCN) now recommends that most patients should be initially placed on active surveillance in absence of progressive or symptomatic disease
+          - Bonvalot et al found that of those tumors assigned to active surveillance 1/3 remained stable and 1/3 actually spontaneously regressed
+    - While surgical treatment was once mainstay of desmoid treatment, this has now increasingly become controversial as result of morbidity and mortality associated with resection (although surgery may still be necessary in some cases)
+          - May be difficult due to involvement of adjacent critical structures
+                  - Particularly when small bowel mesentery involved, surgery can result in significant morbidity (bowel ischemia, short gut syndrome, obstruction, etc.)
+                  - Small bowel transplantation may be option in patients who require resection for intraabdominal desmoid and undergo significant bowel resection
+          - Recurrence after surgery is very common, particularly with extraabdominal desmoids, even if surgical margins are negative
+                  - Exact relationship between negative margins and local recurrence is unclear based on several studies, which is why performing resections that prioritize maintaining local function may be more important than simply trying to achieve R0 resection
+          - Recurrence rates for desmoids is roughly 50% and may be higher for intraabdominal desmoids (57-88%)
+                  - FAP and larger tumor size (> 10 cm) increases risk of recurrence
+    - Conservative management now increasingly utilized for even symptomatic desmoids (in lieu of surgery)
+          - Systemic therapy: Cytotoxic agents (including anthracyclines), antiestrogen agents (e.g., tamoxifen), interferon, molecular-targeted agents (e.g., imatinib), steroids, NSAIDs (e.g., sulindac)
+          - Radiation therapy: Can be effective for establishing local control of tumor, but usually utilized after other options exhausted due to toxicity
+
+# DIAGNOSTIC CHECKLIST
+
+- ## Consider
+  
+  
+    - Consider desmoid tumors in patients with history of prior abdominal surgery
+    - Look for other features of Gardner syndrome
+    - Rule out other more common causes of solid mesenteric mass
+- ## Image Interpretation Pearls
+  
+  
+    - Soft tissue density mesenteric mass ± invasion, displacement, or encasement of bowel loops and vessels
+
+ a8bf5d57-3c71-41da-988e-48a7b21fbd0f
+
+## References
+
+# Selected References
+
+1. [Mangla A et al: Desmoid tumors: current perspective and treatment. Curr Treat Options Oncol. 25(2):161-75, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38270798%5Bpmid%5D)
+1. [Moore D et al: Surgical management of abdominal desmoids: a systematic review and meta-analysis. Ir J Med Sci. 192(2):549-60, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=35445926%5Bpmid%5D)
+1. [Yang W et al: Update on familial adenomatous polyposis-associated desmoid tumors. Clin Colon Rectal Surg. 36(6):400-5, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=37795470%5Bpmid%5D)
+1. [Marsh-Armstrong B et al: Pregnancy-associated large pelvic desmoid tumor: a case report of fetal-protective strategies and fertility preservation. Gynecol Oncol Rep. 39:100901, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35531359%5Bpmid%5D)
+1. [Ballard DH et al: Imaging of abdominal wall masses, masslike lesions, and diffuse processes. Radiographics. 40(3):684-706, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32330085%5Bpmid%5D)
+1. [Garcia-Ortega DY et al: Desmoid-type fibromatosis. Cancers (Basel). 12(7), 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32660036%5Bpmid%5D)
+1. [Hartung MP et al: Mimics of malignancy in abdominal imaging: multisystem radiology. Radiographics. 37(7):2202-3, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29131766%5Bpmid%5D)
+1. [Howard JH et al: Intra-abdominal and abdominal wall desmoid fibromatosis. Oncol Ther. 4(1):57-72, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=28261640%5Bpmid%5D)
+1. [Bonvalot S et al: Spontaneous regression of primary abdominal wall desmoid tumors: more common than previously thought. Ann Surg Oncol. 20(13):4096-102, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24052312%5Bpmid%5D)
+1. [Lamboley JL et al: Desmoid tumour of the chest wall. Diagn Interv Imaging. 93(7-8):635-8, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22721603%5Bpmid%5D)
+1. [Roy AG: Desmoid tumors. Am Surg. 78(2):79-80, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22369803%5Bpmid%5D)
+1. [Shinagare AB et al: A to Z of desmoid tumors. AJR Am J Roentgenol. 197(6):W1008-14, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22109314%5Bpmid%5D)
+1. [McDonald ES et al: Best cases from the AFIP: extraabdominal desmoid-type fibromatosis. Radiographics. 28(3):901-6, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18480491%5Bpmid%5D)
+1. [Dinauer PA et al: Pathologic and MR imaging features of benign fibrous soft-tissue tumors in adults. Radiographics. 27(1):173-87, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17235006%5Bpmid%5D)
+1. [McCarville MB et al: MRI and biologic behavior of desmoid tumors in children. AJR Am J Roentgenol. 189(3):633-40, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17715111%5Bpmid%5D)
+1. [Lee JC et al: Aggressive fibromatosis: MRI features with pathologic correlation. AJR Am J Roentgenol. 186(1):247-54, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16357411%5Bpmid%5D)
+1. [Levy AD et al: From the archives of the AFIP: benign fibrous tumors and tumorlike lesions of the mesentery: radiologic-pathologic correlation. Radiographics. 26(1):245-64, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16418255%5Bpmid%5D)
+1. [Azizi L et al: MRI features of mesenteric desmoid tumors in familial adenomatous polyposis. AJR Am J Roentgenol. 184(4):1128-35, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15788583%5Bpmid%5D)
+1. [Sheth S et al: Mesenteric neoplasms: CT appearances of primary and secondary tumors and differential diagnosis. Radiographics. 23(2):457-73; quiz 535-6, 2003](http://www.ncbi.nlm.nih.gov/pubmed/?term=12640160%5Bpmid%5D)
+1. [Healy JC et al: MR appearances of desmoid tumors in familial adenomatous polyposis. AJR Am J Roentgenol. 169(2):465-72, 1997](http://www.ncbi.nlm.nih.gov/pubmed/?term=9242755%5Bpmid%5D)
+1. [Mindelzun RE et al: The misty mesentery on CT: differential diagnosis. AJR Am J Roentgenol. 167(1):61-5, 1996](http://www.ncbi.nlm.nih.gov/pubmed/?term=8659422%5Bpmid%5D)
+1. [Ichikawa T et al: Abdominal wall desmoid mimicking intra-abdominal mass: MR features. Magn Reson Imaging. 12(3):541-4, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8007785%5Bpmid%5D)
+1. [Kawashima A et al: CT of intraabdominal desmoid tumors: is the tumor different in patients with Gardner's disease? AJR Am J Roentgenol. 162(2):339-42, 1994](http://www.ncbi.nlm.nih.gov/pubmed/?term=8310922%5Bpmid%5D)
+1. [Casillas J et al: Imaging of intra- and extraabdominal desmoid tumors. Radiographics. 11(6):959-68, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1749859%5Bpmid%5D)
+1. [Einstein DM et al: Abdominal desmoids: CT findings in 25 patients. AJR Am J Roentgenol. 157(2):275-9, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1853806%5Bpmid%5D)
+1. [Baron RL et al: Mesenteric desmoid tumors: sonographic and computed-tomographic appearance. Radiology. 140(3):777-9, 1981](http://www.ncbi.nlm.nih.gov/pubmed/?term=7280249%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![Axial CECT demonstrates a large,  homogeneous mass <img src='img/arrows/WS.png'/> in the deep pelvis involving the rectosigmoid colon and portions of the small bowel. While this was prospectively thought to perhaps be a gastrointestinal stromal tumor on imaging, it turned out to be a desmoid tumor at resection.](images/app.statdx.com_image_thumbnail_677784d6-e84c-45ae-aee2-d22177a30922_annotated_true_size_900_quality_90_1676c92e3bc1610d7c8141af4322aed97f1ddbbd.jpg)
+*Axial CECT demonstrates a large,  homogeneous mass <img src='img/arrows/WS.png'/> in the deep pelvis involving the rectosigmoid colon and portions of the small bowel. While this was prospectively thought to perhaps be a gastrointestinal stromal tumor on imaging, it turned out to be a desmoid tumor at resection.*
+
+![Axial CECT demonstrates a large,  homogeneous mass <img src='img/arrows/WS.png'/> in the deep pelvis involving the rectosigmoid colon and portions of the small bowel. While this was prospectively thought to perhaps be a gastrointestinal stromal tumor on imaging, it turned out to be a desmoid tumor at resection.](images/app.statdx.com_image_thumbnail_677784d6-e84c-45ae-aee2-d22177a30922_size_174_quality_85_6886bf35d30b9feaf9798bddfe08bfa1caf4f73e.jpg)
+*Axial CECT demonstrates a large,  homogeneous mass <img src='img/arrows/WS.png'/> in the deep pelvis involving the rectosigmoid colon and portions of the small bowel. While this was prospectively thought to perhaps be a gastrointestinal stromal tumor on imaging, it turned out to be a desmoid tumor at resection.*
+
+![Axial CECT demonstrates a homogeneous mass <img src='img/arrows/WS.png'/> in the right psoas muscle that was incidentally discovered on imaging done for other reasons. This was shown to be a desmoid tumor on biopsy.](images/app.statdx.com_image_thumbnail_75cb8898-5f40-4826-adac-6e0080d9f7da_annotated_true_size_900_quality_90_813d6a7ff1c7a16ef20d3f345cc95e9a056d3961.jpg)
+*Axial CECT demonstrates a homogeneous mass <img src='img/arrows/WS.png'/> in the right psoas muscle that was incidentally discovered on imaging done for other reasons. This was shown to be a desmoid tumor on biopsy.*
+
+![Sagittal T2 MR demonstrates a relatively T2-hypointense mass <img src='img/arrows/WS.png'/> in the subcutaneous soft tissues of the posterior pelvic wall in a patient who had felt this mass growing over time.](images/app.statdx.com_image_thumbnail_f66790f1-518a-4b36-8ddc-fd471c58dd9f_annotated_true_size_900_quality_90_fe72f41ede5dc3b4ea0f9d5aa947d84379460486.jpg)
+*Sagittal T2 MR demonstrates a relatively T2-hypointense mass <img src='img/arrows/WS.png'/> in the subcutaneous soft tissues of the posterior pelvic wall in a patient who had felt this mass growing over time.*
+
+![Axial T1 C+ FS MR in the same patient demonstrates that the mass exhibits substantial enhancement with mildly irregular margins <img src='img/arrows/WS.png'/>. This was found to be a desmoid tumor at resection.](images/app.statdx.com_image_thumbnail_88788c10-81aa-48d7-ac0a-037574809eb0_annotated_true_size_900_quality_90_a3e50bf362b56d3627d35c9f8f214aca63bfa451.jpg)
+*Axial T1 C+ FS MR in the same patient demonstrates that the mass exhibits substantial enhancement with mildly irregular margins <img src='img/arrows/WS.png'/>. This was found to be a desmoid tumor at resection.*
+
+![Axial CECT demonstrates a homogeneously enhancing mass  <img src='img/arrows/WS.png'/>  in the right hemipelvis.](images/app.statdx.com_image_thumbnail_7b7b2c88-a1da-446c-a10a-14d667ecc03e_annotated_true_size_900_quality_90_d40ea257fc184cb922d0458bc29bb7f24c88ed42.jpg)
+*Axial CECT demonstrates a homogeneously enhancing mass  <img src='img/arrows/WS.png'/>  in the right hemipelvis.*
+
+![Axial CECT in the same patient demonstrates a large avidly enhancing mass <img src='img/arrows/WS.png'/> in the right lower quadrant. This was a patient with familial adenomatous polyposis (FAP), and both of these lesions were found to represent desmoid tumors.](images/app.statdx.com_image_thumbnail_63868f0d-45cd-4b16-b301-3382fcf0e63b_annotated_true_size_900_quality_90_1e2086f2d6f7ecd6fa87405209e930b1f61613fb.jpg)
+*Axial CECT in the same patient demonstrates a large avidly enhancing mass <img src='img/arrows/WS.png'/> in the right lower quadrant. This was a patient with familial adenomatous polyposis (FAP), and both of these lesions were found to represent desmoid tumors.*
+
+![Axial CECT shows a large mesenteric desmoid <img src='img/arrows/WS.png'/> with involvement of multiple bowel loops that had been slowly growing on serial examinations. The patient underwent surgical resection, but desmoids with extensive bowel involvement can often be very difficult to resect.](images/app.statdx.com_image_thumbnail_4ec30596-18f6-49b8-bad2-a5e163173886_annotated_true_size_900_quality_90_f9e2c6707edd789bac111a32d9114a39c3e223cc.jpg)
+*Axial CECT shows a large mesenteric desmoid <img src='img/arrows/WS.png'/> with involvement of multiple bowel loops that had been slowly growing on serial examinations. The patient underwent surgical resection, but desmoids with extensive bowel involvement can often be very difficult to resect.*
+
+![Axial CECT demonstrates a well- circumscribed, homogenous mass <img src='img/arrows/WS.png'/> in the pelvis involving the colon and small bowel, found to be a desmoid tumor at resection.](images/app.statdx.com_image_thumbnail_df3d4f3a-38e8-42f6-81a6-4910ea39350c_annotated_true_size_900_quality_90_18a5b0c26b2e058c5021d85afab3d42033a8f853.jpg)
+*Axial CECT demonstrates a well- circumscribed, homogenous mass <img src='img/arrows/WS.png'/> in the pelvis involving the colon and small bowel, found to be a desmoid tumor at resection.*
+
+![Coronal T2 HASTE MR in a patient who had undergone bowel resection roughly 6 months earlier demonstrates a well-circumscribed,  T2-hypointense mass <img src='img/arrows/WS.png'/> in very close proximity to the surgical site.](images/app.statdx.com_image_thumbnail_4c143392-69ef-4b73-a37b-c758b5b304dc_annotated_true_size_900_quality_90_86d69777b5d983334b5e8e62c931bac3710c3888.jpg)
+*Coronal T2 HASTE MR in a patient who had undergone bowel resection roughly 6 months earlier demonstrates a well-circumscribed,  T2-hypointense mass <img src='img/arrows/WS.png'/> in very close proximity to the surgical site.*
+
+![Axial T1 C+ MR in the same patient demonstrates that the mass <img src='img/arrows/WS.png'/> demonstrates homogeneous enhancement,  which increases on this delayed phase image. Because of their fibrotic component, desmoids can demonstrate relative T2 hypointensity and increasing delayed enhancement, as in this case.](images/app.statdx.com_image_thumbnail_035d47d6-a35f-49ca-8cdf-9a839d746521_annotated_true_size_900_quality_90_b21a924a70917949957c554cdd3542e5dfe1cc7a.jpg)
+*Axial T1 C+ MR in the same patient demonstrates that the mass <img src='img/arrows/WS.png'/> demonstrates homogeneous enhancement,  which increases on this delayed phase image. Because of their fibrotic component, desmoids can demonstrate relative T2 hypointensity and increasing delayed enhancement, as in this case.*
+
+
+### Additional Images
+
+![Axial CECT in a 36-year-old man 12 months following a colectomy for Gardner syndrome shows a solid mesenteric desmoid <img src='img/arrows/WS.png'/>.](images/app.statdx.com_image_thumbnail_b7d1d41c-7d88-42ac-a841-9caff9d7ce1d_annotated_true_size_900_quality_90_32da45ab29ab88ac76da0d777faa2e56cb282fee.jpg)
+*Axial CECT in a 36-year-old man 12 months following a colectomy for Gardner syndrome shows a solid mesenteric desmoid <img src='img/arrows/WS.png'/>.*
+
+![Axial CECT 20 months following a colectomy for Gardner syndrome shows rapid growth of a mesenteric mass (desmoid tumor).](4e910656-756f-40ea-96d7-0e4233d1ebf0)
+*Axial CECT 20 months following a colectomy for Gardner syndrome shows rapid growth of a mesenteric mass (desmoid tumor).*
+
+![Axial CECT shows desmoid in the subcutaneous tissue <img src='img/arrows/WS.png'/> adjacent to a scar from a prior paramedian incision.](616faf94-2d89-4e2c-ac5a-2c36fb5e4156)
+*Axial CECT shows desmoid in the subcutaneous tissue <img src='img/arrows/WS.png'/> adjacent to a scar from a prior paramedian incision.*
+
+![Axial CECT shows multiple omental masses <img src='img/arrows/WS.png'/> near the site of prior colon surgery, representing desmoid tumors. Note the surgical clip <img src='img/arrows/WO.png'/>.](46a0e9fb-b5a7-4cde-9964-cbed0ee905a9)
+*Axial CECT shows multiple omental masses <img src='img/arrows/WS.png'/> near the site of prior colon surgery, representing desmoid tumors. Note the surgical clip <img src='img/arrows/WO.png'/>.*
+
+![Axial CECT in a patient with Gardner syndrome shows a large, bilobed, mesenteric desmoid tumor.](20aca44e-0bb6-459f-aae6-e08ef98e5a79)
+*Axial CECT in a patient with Gardner syndrome shows a large, bilobed, mesenteric desmoid tumor.*
+
+![Axial NECT in a patient with Gardner syndrome shows desmoid tumors filling the abdomen, obstructing kidneys and deforming the abdominal wall.](84fdec19-667f-46b6-a9bb-47b7146f3d6b)
+*Axial NECT in a patient with Gardner syndrome shows desmoid tumors filling the abdomen, obstructing kidneys and deforming the abdominal wall.*
+
+![Axial CECT in a 79-year-old woman shows a homogeneous omental mass <img src='img/arrows/WS.png'/>. This was a sporadic form of desmoid.](1613e69e-49b7-43ff-a900-6a0f5ceb2d0c)
+*Axial CECT in a 79-year-old woman shows a homogeneous omental mass <img src='img/arrows/WS.png'/>. This was a sporadic form of desmoid.*
+
+![Axial NECT in a 79-year-old woman shows a homogeneous, enhancing mass<img src='img/arrows/WS.png'/> in the left pelvis. CT-guided biopsy showed a &quot;rock hard&quot; mass but enough tissue to confirm desmoid tumor.](d1cca037-b001-4d3a-8376-f50d113dd123)
+*Axial NECT in a 79-year-old woman shows a homogeneous, enhancing mass<img src='img/arrows/WS.png'/> in the left pelvis. CT-guided biopsy showed a &quot;rock hard&quot; mass but enough tissue to confirm desmoid tumor.*
+
+![Axial CECT demonstrates a very well-circumscribed, relatively hypoenhancing mass <img src='img/arrows/WS.png'/> in the right anterior abdominal wall musculature in a patient with a prior history of a surgical incision in this location, representing a desmoid tumor.](771629f8-72aa-4e03-ba9b-8476faf6b0cd)
+*Axial CECT demonstrates a very well-circumscribed, relatively hypoenhancing mass <img src='img/arrows/WS.png'/> in the right anterior abdominal wall musculature in a patient with a prior history of a surgical incision in this location, representing a desmoid tumor.*
+
+![Axial CECT demonstrates a hypodense soft tissue mass <img src='img/arrows/WS.png'/> in the left mesentery in close proximity to the jejunum, stomach, and pancreas. There is a some surrounding fat stranding and inflammatory change.](62fadba6-6a00-451f-8383-10581df016a9)
+*Axial CECT demonstrates a hypodense soft tissue mass <img src='img/arrows/WS.png'/> in the left mesentery in close proximity to the jejunum, stomach, and pancreas. There is a some surrounding fat stranding and inflammatory change.*
+
+![Axial T2 FS MR in the same patient demonstrates that the mass has both cystic <img src='img/arrows/WO.png'/> and solid <img src='img/arrows/BO.png'/> components. This was originally thought to possibly represent a jejunal gastrointestinal stromal tumor, but was found to be a sporadic desmoid in a patient without risk factors.](e74806cf-5b58-4de5-897c-30b1ceb36983)
+*Axial T2 FS MR in the same patient demonstrates that the mass has both cystic <img src='img/arrows/WO.png'/> and solid <img src='img/arrows/BO.png'/> components. This was originally thought to possibly represent a jejunal gastrointestinal stromal tumor, but was found to be a sporadic desmoid in a patient without risk factors.*
+
+![Axial CT reveals a solid mass <img src='img/arrows/WS.png'/> that involves the lower rectus muscle. This is a surgically proven desmoid tumor. In Gardner syndrome, desmoids may involve the mesentery or abdominal wall. As with other types of fibrous masses, such as keloids, sites of prior surgery or trauma are commonly involved.](ac6cde73-ed4e-40f0-80f5-ee37fdf14b83)
+*Axial CT reveals a solid mass <img src='img/arrows/WS.png'/> that involves the lower rectus muscle. This is a surgically proven desmoid tumor. In Gardner syndrome, desmoids may involve the mesentery or abdominal wall. As with other types of fibrous masses, such as keloids, sites of prior surgery or trauma are commonly involved.*
+
+![Axial CT in the same patient again reveals a solid mass <img src='img/arrows/WS.png'/> that involves the lower rectus muscle. This was a surgically proven desmoid tumor. In Gardner syndrome, desmoids may involve the mesentery or abdominal wall. As with other types of fibrous masses, such as keloids, sites of prior surgery or trauma are commonly involved.](330bb7ba-e4db-4ffa-8c49-7e35d12569ad)
+*Axial CT in the same patient again reveals a solid mass <img src='img/arrows/WS.png'/> that involves the lower rectus muscle. This was a surgically proven desmoid tumor. In Gardner syndrome, desmoids may involve the mesentery or abdominal wall. As with other types of fibrous masses, such as keloids, sites of prior surgery or trauma are commonly involved.*
+
+![Axial CECT shows an isolated mesenteric desmoid in a 24-year-old woman with no personal evidence of colonic polyps but a family history of familial polyposis. Note the infiltrative mesenteric mass <img src='img/arrows/WC.png'/>.](9dd406b0-101f-4ce9-a5ba-b29ff2c073bf)
+*Axial CECT shows an isolated mesenteric desmoid in a 24-year-old woman with no personal evidence of colonic polyps but a family history of familial polyposis. Note the infiltrative mesenteric mass <img src='img/arrows/WC.png'/>.*
+
+![Axial CECT in a 75-year-old Black woman shows an isolated mesenteric desmoid as a nonspecific soft tissue density mass <img src='img/arrows/WS.png'/> adjacent to the bladder <img src='img/arrows/WO.png'/>, uterus, and colon. A core needle biopsy was requested. The mass was extremely hard and bent each of the biopsy needles.](e0bf9a0c-c80e-44c8-9c6e-108ec1614914)
+*Axial CECT in a 75-year-old Black woman shows an isolated mesenteric desmoid as a nonspecific soft tissue density mass <img src='img/arrows/WS.png'/> adjacent to the bladder <img src='img/arrows/WO.png'/>, uterus, and colon. A core needle biopsy was requested. The mass was extremely hard and bent each of the biopsy needles.*
+
+![Axial CECT demonstrates a soft tissue mass  <img src='img/arrows/WS.png'/>  in the left upper quadrant with surrounding soft tissue edema and induration, found to represent a desmoid at resection.](f16ae35a-cf80-4fca-9388-34467023cd78)
+*Axial CECT demonstrates a soft tissue mass  <img src='img/arrows/WS.png'/>  in the left upper quadrant with surrounding soft tissue edema and induration, found to represent a desmoid at resection.*
+
+![Axial CECT demonstrates a very homogeneous, hypoenhancing mass <img src='img/arrows/WS.png'/> in the pelvis encasing loops of adjacent bowel. This was found to be a desmoid tumor. Desmoids with extensive involvement of the bowel can be very difficult to surgically resect.](addb50cd-8125-45a0-994f-2aa8d2027eb7)
+*Axial CECT demonstrates a very homogeneous, hypoenhancing mass <img src='img/arrows/WS.png'/> in the pelvis encasing loops of adjacent bowel. This was found to be a desmoid tumor. Desmoids with extensive involvement of the bowel can be very difficult to surgically resect.*
+
+![Axial CECT demonstrates a relatively homogeneous, enhancing, well-circumscribed mass <img src='img/arrows/WS.png'/> in the right anterior pelvis.](df08adb1-00b6-457f-b1cd-9ef5fe09198f)
+*Axial CECT demonstrates a relatively homogeneous, enhancing, well-circumscribed mass <img src='img/arrows/WS.png'/> in the right anterior pelvis.*
+
+![Axial CECT in the same patient demonstrates a very similar-appearing smaller mass <img src='img/arrows/WS.png'/> in the more inferior pelvis. This was a patient with Gardner syndrome, and both of these lesions were found to represent desmoid tumors.](36ce12b9-cad1-46e2-9b86-8a6df02dbfbd)
+*Axial CECT in the same patient demonstrates a very similar-appearing smaller mass <img src='img/arrows/WS.png'/> in the more inferior pelvis. This was a patient with Gardner syndrome, and both of these lesions were found to represent desmoid tumors.*
+
+![Axial T1WI C+ FS MR in the same patient demonstrates relatively avid enhancement of the mass <img src='img/arrows/WS.png'/>, which is once again noted to be quite infiltrative and poorly marginated. In cases like this, only histologic confirmation can differentiate a desmoid from a soft tissue malignancy.](739c342f-3420-4c3d-9d48-c58e73d74ad7)
+*Axial T1WI C+ FS MR in the same patient demonstrates relatively avid enhancement of the mass <img src='img/arrows/WS.png'/>, which is once again noted to be quite infiltrative and poorly marginated. In cases like this, only histologic confirmation can differentiate a desmoid from a soft tissue malignancy.*
+
+![Axial CECT demonstrates an infiltrative, hypoenhancing mass <img src='img/arrows/WS.png'/> in the right anterior abdominal wall musculature at the site of a prior surgical incision.](469b4a04-c83e-49b8-b8b0-fc67b50ad676)
+*Axial CECT demonstrates an infiltrative, hypoenhancing mass <img src='img/arrows/WS.png'/> in the right anterior abdominal wall musculature at the site of a prior surgical incision.*
+
+![Axial CECT in a young woman with Gardner syndrome 2 years after total colectomy shows mesenteric fibromatosis (desmoids) encasing the entire small bowel mesentery, filling the abdominal cavity.](63651c37-19b6-4dbc-aed2-ff6c0285514a)
+*Axial CECT in a young woman with Gardner syndrome 2 years after total colectomy shows mesenteric fibromatosis (desmoids) encasing the entire small bowel mesentery, filling the abdominal cavity.*
+

docs_md/articles/elevated-or-deformed-hemidiaphragm_208baaa2-8772-4560-af34-46ce757edcb9.md

@@ -0,0 +1,185 @@
+---
+title: "Elevated or Deformed Hemidiaphragm"
+docid: "208baaa2-8772-4560-af34-46ce757edcb9"
+authors:
+  - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+    value: "Siva P. Raman, MD"
+breadcrumbs:
+  -
+    name: "Gastrointestinal"
+    slug: "gastrointestinal"
+    treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+  -
+    name: "Differential Diagnosis"
+    slug: "differential-diagnosis"
+    treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+  -
+    name: "Abdominal Wall"
+    slug: "abdominal-wall"
+    treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+  -
+    name: "Anatomically Based Differentials"
+    slug: "anatomically-based-differentials"
+    treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+  -
+    name: "Elevated or Deformed Hemidiaphragm"
+    slug: "elevated-or-deformed-hemidiaphragm"
+    treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "c5d9083d-d7a6-430b-9be6-4a6013d67387"
+imageCount: 18
+lastUpdated: "07/01/22"
+pageDescription: "Elevated or Deformed Hemidiaphragm"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Elevated or Deformed Hemidiaphragm"
+pageTitle: "Elevated or Deformed Hemidiaphragm | STATdx"
+enhancedTitle: "Elevated or Deformed Hemidiaphragm"
+type: "DDX"
+references: true
+breadcrumbs:
+  - "Gastrointestinal"
+  - "Differential Diagnosis"
+  - "Abdominal Wall"
+  - "Anatomically Based Differentials"
+  - "Elevated or Deformed Hemidiaphragm"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+  
+  
+    - Axial CT suboptimal for distinguishing diaphragm from spleen, liver, and muscle and identifying many diaphragmatic abnormalities
+          - Multiplanar reformations critical for accurate diagnosis
+    - Diaphragm easier to visualize discretely on MR compared to CT and can demonstrate diaphragm in multiple planes
+    - Fluoroscopy and US useful for providing functional information, particularly for paralysis
+          - Dynamic MR (not widely utilized) can provide functional information similar to US or fluoroscopy
+    - US in sagittal plane easily identifies diaphragm and location of peridiaphragmatic fluid collection
+    - Ascites and abdominal contents lie medial to and within confines of diaphragm
+    - Pleural fluid and thoracic contents lie outside confines of diaphragm
+- ## Helpful Clues for Common Diagnoses
+  
+  
+    - **Paralyzed Diaphragm**
+          - Normal diaphragm that fails to contract secondary to abnormalities of brain, spinal cord, neuromuscular junction, phrenic nerve, or muscle
+          - US or fluoroscopy demonstrate no motion or paradoxical (upward) motion during inspiration or sniff test
+    - **Eventration of Diaphragm**
+          - Congenital thinning/weakness of portion of diaphragm, which normally attaches to costal margin
+          - Eccentric diaphragmatic contour (usually anteromedial right hemidiaphragm) ± paradoxical motion with large eventrations
+    - **Hiatal Hernia**
+          - Herniation of abdominal contents into thoracic cavity through esophageal hiatus
+          - Divided into sliding type (GE junction displaced upward through hiatus) and paraesophageal type (GE junction in normal location with stomach herniating above diaphragm)
+    - **Bochdalek Hernia**
+          - Type of congenital diaphragmatic hernia due to defect in posterolateral diaphragm (usually on left side)
+          - Hernia may contain retroperitoneal fat, bowel, kidney, stomach, spleen, or liver
+    - **Morgagni Hernia**
+          - Type of congenital diaphragmatic hernia due to defect in retrosternal diaphragm (usually on right side)
+          - Usually located in right cardiophrenic angle and most often contains just omental fat (but can contain colon, liver, small bowel, or stomach)
+    - **Traumatic Diaphragmatic Hernia**
+          - Traumatic injury may be due to blunt or penetrating trauma
+          - Multiple imaging signs of injury include dependent viscus sign, collar sign, and dangling diaphragm sign
+          - Injuries both above and below diaphragm should raise concern for diaphragmatic injury
+    - **Subdiaphragmatic Mass**
+          - Tumor, hepatomegaly, or splenomegaly can exert mass effect and raise ipsilateral diaphragm
+    - **Abdominal****Abscess**
+          - Subphrenic abscess can cause upward displacement of diaphragm due to mass effect or splinting (decreased motion of diaphragm due to pain)
+    - **Unilateral Lung Volume Loss**
+          - Diminished unilateral lung volume (lung resection, atelectasis) will cause elevation of ipsilateral diaphragm
+    - **Subpulmonic Pleural Effusion (Mimic)**
+          - Pleural fluid loculated in subpulmonic pleural space will displace lung upward and may simulate elevated diaphragm on radiographs (but not on cross-sectional imaging)
+
+## References
+
+# Selected References
+
+1. [Abdellatif W et al: Unravelling the mysteries of traumatic diaphragmatic injury: an up-to-date review. Can Assoc Radiol J. 71(3):313-21, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32157897%5Bpmid%5D)
+1. [Kharma N: Dysfunction of the diaphragm: imaging as a diagnostic tool. Curr Opin Pulm Med. 19(4):394-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23715292%5Bpmid%5D)
+1. [Nason LK et al: Imaging of the diaphragm: anatomy and function. Radiographics. 32(2):E51-70, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22411950%5Bpmid%5D)
+1. [Roberts HC: Imaging the diaphragm. Thorac Surg Clin. 19(4):431-50, v, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=20112626%5Bpmid%5D)
+1. [Verhey PT et al: Differentiating diaphragmatic paralysis and eventration. Acad Radiol. 2007 Apr;14(4):420-5](http://www.ncbi.nlm.nih.gov/pubmed/?term=17368210%5Bpmid%5D)
+1. [Eren S et al: Imaging of diaphragmatic rupture after trauma. Clin Radiol. 61(6):467-77, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16713417%5Bpmid%5D)
+1. [Eren S et al: Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 54(3):448-59, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15899350%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).](images/app.statdx.com_image_thumbnail_27987cfb-8854-4a96-a958-9493891fa27f_annotated_true_size_900_quality_90_2fe0bc4785f5babcbbcfe01b8e100034c4fdc97e.jpg)
+**Paralyzed Diaphragm**
+*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).*
+
+![Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).](images/app.statdx.com_image_thumbnail_27987cfb-8854-4a96-a958-9493891fa27f_size_174_quality_85_a57c68423eacee7703b8df56ddc5ecb8c50f0b5e.jpg)
+**Paralyzed Diaphragm**
+*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed due to phrenic nerve involvement by the patient's mediastinal lymphoma (not shown).*
+
+![Coronal CECT shows the characteristic appearance of diaphragmatic eventration with focal scalloping of the right anterior hemidiaphragm and superior protrusion of the liver at the site of eventration <img src='img/arrows/WS.png'/>.](images/app.statdx.com_image_thumbnail_cb4d7feb-f8ee-442f-8392-e1844a0ad1d4_annotated_true_size_900_quality_90_10961a0580f3d358c486b0eec9dc7e28ef230462.jpg)
+**Eventration of Diaphragm**
+*Coronal CECT shows the characteristic appearance of diaphragmatic eventration with focal scalloping of the right anterior hemidiaphragm and superior protrusion of the liver at the site of eventration <img src='img/arrows/WS.png'/>.*
+
+![Coronal CECT shows a large hiatal hernia with the entirety of the stomach <img src='img/arrows/WS.png'/> located within the thoracic cavity.](images/app.statdx.com_image_thumbnail_db2a7b93-07d5-429f-8607-e9be61727fe9_annotated_true_size_900_quality_90_ec9734f4a8c5da6d41cae39057e3e5e404937f25.jpg)
+**Hiatal Hernia**
+*Coronal CECT shows a large hiatal hernia with the entirety of the stomach <img src='img/arrows/WS.png'/> located within the thoracic cavity.*
+
+![Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm <img src='img/arrows/WO.png'/> with herniation of the kidney <img src='img/arrows/WS.png'/> into the thorax.](images/app.statdx.com_image_thumbnail_facbda67-44b9-4fc9-b95f-797ab6e4d7d4_annotated_true_size_900_quality_90_d53e433decf1c199ee1ff0cadde4370dfcaf6062.jpg)
+**Bochdalek Hernia**
+*Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm <img src='img/arrows/WO.png'/> with herniation of the kidney <img src='img/arrows/WS.png'/> into the thorax.*
+
+![Coronal NECT shows a characteristic Morgagni hernia with omental fat herniating into the chest through a defect <img src='img/arrows/WS.png'/> in the right anteromedial diaphragm.](00f3a3e9-c7a7-45ac-9e6c-6caa0166970a)
+**Morgagni Hernia**
+*Coronal NECT shows a characteristic Morgagni hernia with omental fat herniating into the chest through a defect <img src='img/arrows/WS.png'/> in the right anteromedial diaphragm.*
+
+![Sagittal T2 MR shows a posttraumatic defect <img src='img/arrows/WS.png'/> in the left hemidiaphragm with the stomach <img src='img/arrows/WO.png'/> herniating into the chest. Note that the diaphragm is identified as a low-signal curvilinear structure. The stomach is pinched as it traverses the defect in the diaphragm.](25744611-4cea-47f1-ab9f-910d4f5fb8d3)
+**Traumatic Diaphragmatic Hernia**
+*Sagittal T2 MR shows a posttraumatic defect <img src='img/arrows/WS.png'/> in the left hemidiaphragm with the stomach <img src='img/arrows/WO.png'/> herniating into the chest. Note that the diaphragm is identified as a low-signal curvilinear structure. The stomach is pinched as it traverses the defect in the diaphragm.*
+
+![Axial CECT shows the fallen viscus sign associated with traumatic diaphragmatic injury. Note that the stomach <img src='img/arrows/WS.png'/> lies in the chest and has fallen medially and posteriorly to lie against the lung and the posteromedial chest wall.](7f7b3232-eaf2-47a9-9fdb-83afc19ce513)
+**Traumatic Diaphragmatic Hernia**
+*Axial CECT shows the fallen viscus sign associated with traumatic diaphragmatic injury. Note that the stomach <img src='img/arrows/WS.png'/> lies in the chest and has fallen medially and posteriorly to lie against the lung and the posteromedial chest wall.*
+
+![Axial CECT shows a pleural effusion <img src='img/arrows/WS.png'/> below the lung and lateral to the diaphragm <img src='img/arrows/WC.png'/>. Ascites <img src='img/arrows/WO.png'/> lies medial to the diaphragm and adjacent to the cirrhotic liver.](dd9502d7-28db-4747-bd80-f80848a40af6)
+**Subpulmonic Pleural Effusion (Mimic)**
+*Axial CECT shows a pleural effusion <img src='img/arrows/WS.png'/> below the lung and lateral to the diaphragm <img src='img/arrows/WC.png'/>. Ascites <img src='img/arrows/WO.png'/> lies medial to the diaphragm and adjacent to the cirrhotic liver.*
+
+
+### Additional Images
+
+![Axial NECT shows elevation of the left hemidiaphragm <img src='img/arrows/WS.png'/>  without focal bulge or eventration. The abdominal contents do not fall dependently but are suspended by the intact diaphragm.](images/app.statdx.com_image_thumbnail_3f012db7-9b48-468d-a61d-834ca1ed5710_annotated_true_size_900_quality_90_1de9ccee2fc64909300d4151928934fb616d5028.jpg)
+**Paralyzed Diaphragm**
+*Axial NECT shows elevation of the left hemidiaphragm <img src='img/arrows/WS.png'/>  without focal bulge or eventration. The abdominal contents do not fall dependently but are suspended by the intact diaphragm.*
+
+![Sagittal CECT shows a focal bulge of the liver <img src='img/arrows/WO.png'/> through a weakened eventration of the right hemidiaphragm.](images/app.statdx.com_image_thumbnail_250f0a34-c8b3-41a1-9409-5e2d11e8f1ca_annotated_true_size_900_quality_90_d87ca3db8d6584b2d5405fd294a9ee7fc80d9de9.jpg)
+**Eventration of Diaphragm**
+*Sagittal CECT shows a focal bulge of the liver <img src='img/arrows/WO.png'/> through a weakened eventration of the right hemidiaphragm.*
+
+![Axial NECT shows herniation of most of the stomach <img src='img/arrows/WO.png'/> as well as the splenic flexure of colon <img src='img/arrows/WS.png'/> through a massive hiatal hernia.](images/app.statdx.com_image_thumbnail_245521be-9574-408a-a425-c625d96c8fd1_annotated_true_size_900_quality_90_82f3f50106f2cd73f4be8ac0046a149a9bd726c2.jpg)
+**Hiatal Hernia**
+*Axial NECT shows herniation of most of the stomach <img src='img/arrows/WO.png'/> as well as the splenic flexure of colon <img src='img/arrows/WS.png'/> through a massive hiatal hernia.*
+
+![Axial CECT shows bilateral defects <img src='img/arrows/WO.png'/> in the posteromedial portions of the diaphragm with herniation of omental fat.](0492648b-e574-4ee5-b21e-d6336e89c7b3)
+**Bochdalek Hernia**
+*Axial CECT shows bilateral defects <img src='img/arrows/WO.png'/> in the posteromedial portions of the diaphragm with herniation of omental fat.*
+
+![Axial NECT shows a large hiatal hernia <img src='img/arrows/WO.png'/> that contains much of the stomach. There is also a large Morgagni hernia <img src='img/arrows/WS.png'/>, lateral to and displacing the heart, containing omental fat and colon.](2dedb513-12f1-4101-9343-595ce6c84742)
+**Morgagni Hernia**
+*Axial NECT shows a large hiatal hernia <img src='img/arrows/WO.png'/> that contains much of the stomach. There is also a large Morgagni hernia <img src='img/arrows/WS.png'/>, lateral to and displacing the heart, containing omental fat and colon.*
+
+![Coronal T2 MR shows herniation of the stomach <img src='img/arrows/WO.png'/>  and omental fat through a defect in the left hemidiaphragm <img src='img/arrows/WS.png'/>. The stomach is pinched as it traverses the defect in the diaphragm.](1a25212b-8ea7-432f-a296-951628eadc6a)
+**Traumatic Diaphragmatic Hernia**
+*Coronal T2 MR shows herniation of the stomach <img src='img/arrows/WO.png'/>  and omental fat through a defect in the left hemidiaphragm <img src='img/arrows/WS.png'/>. The stomach is pinched as it traverses the defect in the diaphragm.*
+
+![Axial CECT shows herniation of the stomach <img src='img/arrows/WS.png'/> through a defect in the left hemidiaphragm. The stomach has fallen to lie against the posteromedial chest wall and is pinched <img src='img/arrows/WC.png'/>.](3e57f234-7073-43df-b7c2-45ca45bf20d5)
+**Traumatic Diaphragmatic Hernia**
+*Axial CECT shows herniation of the stomach <img src='img/arrows/WS.png'/> through a defect in the left hemidiaphragm. The stomach has fallen to lie against the posteromedial chest wall and is pinched <img src='img/arrows/WC.png'/>.*
+
+![Coronal CECT shows a large hiatal hernia with the entirety of the stomach <img src='img/arrows/WS.png'/> located within the thoracic cavity.](images/app.statdx.com_image_thumbnail_16957dc1-e21a-411f-bca2-feaf4205c901_annotated_true_size_900_quality_90_f78bed64b359de06752585dd6d2b386d4538d4bb.jpg)
+**Hiatal Hernia**
+*Coronal CECT shows a large hiatal hernia with the entirety of the stomach <img src='img/arrows/WS.png'/> located within the thoracic cavity.*
+
+![Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed as a result of phrenic nerve involvement by a mediastinal soft tissue mass <img src='img/arrows/WC.png'/> in this patient with metastatic lung cancer.](images/app.statdx.com_image_thumbnail_fcd59ce5-5f6e-44cd-84ef-4b86ab7a0d9f_annotated_true_size_900_quality_90_d395754a34823401d75d2ca7c23a85cc069f12ed.jpg)
+**Paralyzed Diaphragm**
+*Coronal CECT shows marked asymmetric elevation of the left hemidiaphragm. In this case, the left diaphragm <img src='img/arrows/WS.png'/> is paralyzed as a result of phrenic nerve involvement by a mediastinal soft tissue mass <img src='img/arrows/WC.png'/> in this patient with metastatic lung cancer.*
+
+![Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm <img src='img/arrows/WO.png'/> with herniation of the kidney <img src='img/arrows/WS.png'/> into the thorax.](a2f87274-b815-4f59-9f25-b1ff07ae6215)
+**Bochdalek Hernia**
+*Sagittal CECT shows a large Bochdalek hernia containing bowel and kidney. There is focal interruption of the hemidiaphragm <img src='img/arrows/WO.png'/> with herniation of the kidney <img src='img/arrows/WS.png'/> into the thorax.*
+

docs_md/articles/facial-nerve-cnvii_2f4818dd-6438-405b-8561-5cbbb9c91562.md

@@ -0,0 +1,258 @@
+---
+title: "Facial Nerve (CNVII)"
+docid: "2f4818dd-6438-405b-8561-5cbbb9c91562"
+authors:
+  - key: "94f835c8-fa13-4e8a-995b-53048e6b0605"
+    value: "Philip R. Chapman, MD"
+  - key: "b0a6efa4-ad68-430c-b5da-f5c904adf809"
+    value: "Ryan P. Cabeen, PhD"
+breadcrumbs:
+  -
+    name: "Brain"
+    slug: "brain"
+    treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+  -
+    name: "Anatomy"
+    slug: "anatomy"
+    treeNodeId: "45a4cfd4-910b-4f11-8eba-c887895fdbf8"
+  -
+    name: "Skull Base and Cranial Nerves"
+    slug: "skull-base-and-cranial-nerves"
+    treeNodeId: "95ed8b31-2615-40e8-befe-a6a742a0872a"
+  -
+    name: "Facial Nerve (CNVII)"
+    slug: "facial-nerve-cnvii"
+    treeNodeId: null
+category: "Brain"
+cmeTopicId: "e4cb8b15-b95c-4309-b9d9-c9719f291581"
+documentVersionId: "b4c5e191-d167-409d-9300-1c0a03b77e1a"
+imageCount: 27
+lastUpdated: "10/20/20"
+pageDescription: "Facial Nerve (CNVII)"
+pageKeywords: "Brain, Anatomy, Skull Base and Cranial Nerves, Facial Nerve (CNVII)"
+pageTitle: "Facial Nerve (CNVII) | STATdx"
+enhancedTitle: "Facial Nerve (CNVII)"
+type: "ANATOMY"
+breadcrumbs:
+  - "Brain"
+  - "Anatomy"
+  - "Skull Base and Cranial Nerves"
+  - "Facial Nerve (CNVII)"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+  
+  
+    - Facial nerve (CNVII)
+- ## Synonyms
+  
+  
+    - 7th cranial nerve
+- ## Definitions
+  
+  
+    - CNVII: Cranial nerve that carries motor nerves to muscles of facial expression; parasympathetics to lacrimal, submandibular, and sublingual glands; and taste from anterior 2/3 of tongue
+
+# IMAGING ANATOMY
+
+- ## Overview
+  
+  
+    - Mixed nerve: Motor, parasympathetic, and special sensory (taste)
+    - 2 roots: Motor and sensory (nervus intermedius) roots
+          - Nervus intermedius exits lateral brainstem between motor root of facial and vestibulocochlear nerves, hence its name
+    - 3 nuclei and 4 segments: Intraaxial, cisternal, intratemporal, and extracranial (parotid)
+- ## Nuclei and Intraaxial Segment
+  
+  
+    - 3 nuclei (1 motor, 2 sensory)
+    - **Motor nucleus of facial nerve**
+          - Located in ventrolateral pontine tegmentum
+          - Efferent fibers loop dorsally around CNVI nucleus in floor of 4th ventricle, forming facial colliculus
+          - Fibers then course anterolaterally to exit lateral brainstem at pontomedullary junction
+    - **Superior salivatory nucleus**
+          - Located lateral to CNVII motor nucleus in pons
+          - Efferent **parasympathetic fibers** exit brainstem posterior to CNVII as nervus intermedius
+                  - To submandibular, sublingual, and lacrimal glands
+    - **Solitarius tract nucleus**
+          - Termination of taste sensation fibers from anterior 2/3 of tongue
+          - **Cell bodies** of these fibers in **geniculate ganglion**
+          - Fibers travel within nervus intermedius
+- ## Cisternal Segment
+  
+  
+    - 2 roots in cisternal CNVII
+          - Larger motor root anteriorly
+          - Smaller sensory nervus intermedius posteriorly
+    - Emerge from lateral brainstem at **root exit zone** in pontomedullary junction to enter cerebellopontine angle (CPA) cistern
+          - CNVIII exits brainstem posterior to CNVII
+    - 2 roots join together and pass anterolaterally through CPA cistern with CNVIII to internal auditory canal (IAC)
+- ## Intratemporal Segment
+  
+  
+    - CNVII further divided in T-bone into 4 segments: IAC, labyrinthine, tympanic, and mastoid
+    - **IAC segment**: Porus acusticus to IAC fundus; anterosuperior position above crista falciformis
+    - **Labyrinthine segment**: Connects fundal CNVII to geniculate ganglion (anterior genu)
+    - **Tympanic segment**: Connects anterior to posterior genu, passing under lateral semicircular canal
+    - **Mastoid segment**: Inferiorly directed from posterior genu to stylomastoid foramen
+- ## Extracranial Segment
+  
+  
+    - Main CNVII exits skull base through **stylomastoid foramen** to enter parotid space
+    - Parotid CNVII passes lateral to retromandibular vein
+    - Ramifies within parotid, passes anteriorly to innervate muscles of facial expression
+- ## CNVII Branches
+  
+  
+    - **Greater superficial petrosal nerve**
+          - Arises at geniculate ganglion, passes anteromedially, exits temporal bone via facial hiatus
+          - Carries **parasympathetic** fibers to **lacrimal gland**
+    - **Stapedius nerve**
+          - Arises from high mastoid segment of CNVII
+          - Provides **motor** innervation to **stapedius muscle**
+    - **Chorda tympani nerve**
+          - Arises from lower mastoid segment
+          - Courses across middle ear to exit anterior T-bone
+          - Carries **taste** fibers from **anterior 2/3 of tongue**
+                  - These fibers travel with lingual branch of mandibular division of trigeminal nerve
+    - **Terminal motor branches** to muscles of facial expression
+          - Superior to inferior: Temporal, zygomatic, buccal, mandibular, cervical
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Recommendations
+  
+  
+    - Bone CT best for intratemporal segment of CNVII
+    - MR for intraaxial, cisternal, IAC, and extracranial segments
+    - Do not image routine Bell palsy!
+- ## Imaging Sweet Spots
+  
+  
+    - Include brainstem, CPA cistern, IAC, T-bone, and **parotid** when MR completed for CNVII palsy
+- ## Imaging Pitfalls
+  
+  
+    - Mild enhancement of labyrinthine segment, geniculate ganglion, and proximal tympanic segments of CNVII can be normal on postcontrast T1 MR
+          - Secondary to circumneural arteriovenous plexus
+    - Always check parotid in peripheral CNVII paralysis
+- ## Clinical Issues
+  
+  
+    - Facial nerve paralysis can be central or peripheral
+          - **Central**: Supranuclear injury resulting in paralysis of contralateral muscles of facial expression with forehead sparing
+          - **Peripheral**: Injury to CNVII from brainstem nucleus peripherally, resulting in paralysis of all ipsilateral muscles of facial expression
+                  - If lesion proximal to geniculate ganglion, lacrimation, sound dampening, and taste affected
+                  - If CNVI involved, check pons for lesion
+                  - If CNVIII involved, check CPA-IAC for lesion
+                  - If lacrimation, sound dampening, and taste are variably affected, T-bone lesion possible
+                  - If lacrimation, sound dampening and taste are spared, extracranial CNVII implicated
+
+ ca024fe5-308b-4a45-965f-f5040eddf104
+
+
+## Images
+
+
+### Graphics
+
+![Axial graphic shows CNVII nuclei. Motor nucleus sends out its fibers to circle CNVI nucleus before reaching root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. Solitary tract nucleus receives anterior 2/3 of tongue taste information.](22d61165-f6cb-4f78-83a6-c5b5d308b29f)
+*Axial graphic shows CNVII nuclei. Motor nucleus sends out its fibers to circle CNVI nucleus before reaching root exit zone at the pontomedullary junction. The superior salivatory nucleus sends parasympathetic secretomotor fibers to the lacrimal, submandibular, and sublingual glands. Solitary tract nucleus receives anterior 2/3 of tongue taste information.*
+
+![Sagittal graphic depicts CNVII within the temporal bone. Motor fibers pass through the temporal bone, dropping the stapedius nerve to the stapedius muscle, then exit via the stylomastoid foramen to extracranial CNVII (entirely motor). Parasympathetic fibers from superior salivatory nucleus reach the lacrimal gland via the greater superficial petrosal nerve and submandibular-sublingual glands via the chorda tympanic nerve. The anterior 2/3 of tongue taste fibers come via the chorda tympani nerve.](0b4386a8-e9fb-4c99-a164-15cc8c407918)
+*Sagittal graphic depicts CNVII within the temporal bone. Motor fibers pass through the temporal bone, dropping the stapedius nerve to the stapedius muscle, then exit via the stylomastoid foramen to extracranial CNVII (entirely motor). Parasympathetic fibers from superior salivatory nucleus reach the lacrimal gland via the greater superficial petrosal nerve and submandibular-sublingual glands via the chorda tympanic nerve. The anterior 2/3 of tongue taste fibers come via the chorda tympani nerve.*
+
+![Sagittal graphic depicts extracranial motor branches of the facial nerve.](6e3f5d62-63d5-40e6-8b1c-4dc81cd1f9a3)
+*Sagittal graphic depicts extracranial motor branches of the facial nerve.*
+
+
+### Axial Bone CT
+
+![First of 6 axial bone CT of the left temporal bone presented from superior to inferior shows the labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolaterally over the top of the cochlea.](images/app.statdx.com_image_thumbnail_a57fae21-1b3b-40b1-a4c5-a2b8a7fcfd03_annotated_false_size_900_quality_90_3056e8f1e1bd6fae89115e3ee8c96f692e969a78.jpg)
+*First of 6 axial bone CT of the left temporal bone presented from superior to inferior shows the labyrinthine segment of the facial nerve canal as a C-shaped structure arching anterolaterally over the top of the cochlea.*
+
+![In this image, the labyrinthine segment of CNVII canal terminates in the geniculate fossa. The facial nerve canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from the geniculate fossa, coursing posterolaterally in the axial plane, running under the lateral semicircular canal before turning 90° inferiorly at the posterior genu to become the mastoid segment.](images/app.statdx.com_image_thumbnail_dcedb044-667b-4fdd-9d59-24ca8d83429f_annotated_false_size_900_quality_90_93bba14378bbdbe78ce1d52de677e103cb7d3f67.jpg)
+*In this image, the labyrinthine segment of CNVII canal terminates in the geniculate fossa. The facial nerve canal turns abruptly at the geniculate fossa (anterior genu). The tympanic segment arises from the geniculate fossa, coursing posterolaterally in the axial plane, running under the lateral semicircular canal before turning 90° inferiorly at the posterior genu to become the mastoid segment.*
+
+![At the level of the oval window, the mastoid segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.](images/app.statdx.com_image_thumbnail_66db07c6-fa41-4f8d-b7c3-00eb6fcbf7a2_annotated_false_size_900_quality_90_ccb8afc0a58d6290b9e7cc0f96b137b1bcd8aa42.jpg)
+*At the level of the oval window, the mastoid segment is visible deep to the facial nerve recess. Notice the more medial pyramidal eminence and sinus tympani.*
+
+![Mastoid segment extends ~ 13 mm from the posterior genu to the stylomastoid foramen, coursing inferiorly within the posterior wall of the middle ear cavity. The mastoid segment is related anteriorly to the facial nerve recess and medially to the stapedius muscle within the pyramidal eminence on the posterior wall of the middle ear cavity.](images/app.statdx.com_image_thumbnail_1c8b62f9-06e4-4958-8498-9c6bcc419713_annotated_false_size_900_quality_90_e4350ed176a27a67c9aee6eedb3f7cc6ca729dcc.jpg)
+*Mastoid segment extends ~ 13 mm from the posterior genu to the stylomastoid foramen, coursing inferiorly within the posterior wall of the middle ear cavity. The mastoid segment is related anteriorly to the facial nerve recess and medially to the stapedius muscle within the pyramidal eminence on the posterior wall of the middle ear cavity.*
+
+![At the level of the basal turn of the cochlea, the mastoid segment of the facial nerve is still visible. Both the nerve to the stapedius muscle proximally and the chorda tympani distally branch off the mastoid segment (CNVII).](images/app.statdx.com_image_thumbnail_cd1e4755-417f-49a5-a315-76c94465fd83_annotated_false_size_900_quality_90_5b2b7fefe5fb17856de378e109d6bdbf059b2fa9.jpg)
+*At the level of the basal turn of the cochlea, the mastoid segment of the facial nerve is still visible. Both the nerve to the stapedius muscle proximally and the chorda tympani distally branch off the mastoid segment (CNVII).*
+
+![Image at the level of the stylomastoid foramen is shown. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.](5a4b9591-b7c0-435b-8422-4a6438768bc2)
+*Image at the level of the stylomastoid foramen is shown. Notice the "bell" of the stylomastoid foramen is just anteromedial to the mastoid tip. The mastoid tip protects the facial nerve from traumatic injury as it exits the skull base.*
+
+
+### Coronal Bone CT
+
+![First of 6 coronal bone CT of the left temporal bone presented from posterior to anterior shows the lower mastoid segment of the facial nerve (CNVII) and stylomastoid foramen.](095cc63b-0983-4448-8d6a-f548085adadd)
+*First of 6 coronal bone CT of the left temporal bone presented from posterior to anterior shows the lower mastoid segment of the facial nerve (CNVII) and stylomastoid foramen.*
+
+![At the level of the round window, the posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is medial to the pyramidal eminence.](efa15f64-2384-422a-a628-e7997e95a8b8)
+*At the level of the round window, the posterior genu of the facial nerve can be seen just lateral to the pyramidal eminence. Notice the sinus tympani is medial to the pyramidal eminence.*
+
+![At the level of the oval window, the tympanic segment of the facial nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients with oval window atresia, the facial nerve is found near or within the oval window niche.](05405da4-b597-46a7-a9e6-6dba30c4bd68)
+*At the level of the oval window, the tympanic segment of the facial nerve can be seen coursing under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve. Also note the location relative to the upper margin of the oval window. In patients with oval window atresia, the facial nerve is found near or within the oval window niche.*
+
+![At the level of the anterior margin of the oval window, the tympanic segment of the facial nerve can be seen under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is now not seen. The facial nerve canal bony covering in this area is normally incomplete.](df7921df-8893-461e-a8ff-ad8718c16e87)
+*At the level of the anterior margin of the oval window, the tympanic segment of the facial nerve can be seen under the lateral semicircular canal. Notice the fine bony covering (thin white line) surrounding the facial nerve is now not seen. The facial nerve canal bony covering in this area is normally incomplete.*
+
+![In the anterior middle ear cavity, the labyrinthine segment of the facial nerve can be seen exiting the internal auditory canal over the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve.](8f6f8791-4f0e-4324-a5f7-11ad22868e5e)
+*In the anterior middle ear cavity, the labyrinthine segment of the facial nerve can be seen exiting the internal auditory canal over the top of the cochlea. The anterior tympanic segment of the facial nerve is also visible. Do not confuse the muscle-tendon of the tensor tympani in the cochleariform process with the facial nerve.*
+
+![In the most anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is seen within the geniculate fossa as an ovoid structure just above the cochlea.](9d1cfd53-22f8-44d6-b9e8-264435f267ab)
+*In the most anterior portion of middle ear cavity (where both the carotid and the cochlea are visible), the geniculate ganglion is seen within the geniculate fossa as an ovoid structure just above the cochlea.*
+
+
+### 3T Axial T2 & T1 MR
+
+![First of 2 axial high-resolution T2 MR through the cerebellopontine angle cistern and internal auditory canal is shown. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it crosses through the cerebellopontine angle cistern.](56b6d73f-7378-430c-8b39-fbad695093da)
+*First of 2 axial high-resolution T2 MR through the cerebellopontine angle cistern and internal auditory canal is shown. The facial nerve root exit zone is seen anterior to the vestibulocochlear nerve in the pontomedullary junction bilaterally. Notice the facial nerve maintains an anterior relationship with the vestibulocochlear nerve as it crosses through the cerebellopontine angle cistern.*
+
+![Image through the cephalad internal auditory canal on the patient's left shows the facial nerve anterior to the superior vestibular nerve throughout its internal auditory canal course.](254462b9-1184-4948-8207-53014dbef48e)
+*Image through the cephalad internal auditory canal on the patient's left shows the facial nerve anterior to the superior vestibular nerve throughout its internal auditory canal course.*
+
+![Axial T1 MR at the level of the stylomastoid foramen shows the exiting low-signal facial nerve surrounded by high-signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this area is obscured.](5731c57b-385f-4e08-9826-d80e556ac84b)
+*Axial T1 MR at the level of the stylomastoid foramen shows the exiting low-signal facial nerve surrounded by high-signal fat in the "bell" of the stylomastoid foramen. If perineural parotid malignancy is present, the fat in this area is obscured.*
+
+
+### 3T Oblique Sagittal T2 MR
+
+![First of 3 oblique sagittal T2 MR presented from lateral to medial shows normal fundal anatomy. The horizontal crista falciformis separates the fundus into the upper and lower portions. The facial nerve is anterosuperior, separated from the superior vestibular nerve by a vertical bony septum called the "Bill bar," which is not resolved. Below the falciform crest are the larger anterior cochlear nerve and posterior inferior vestibular nerve.](a3eea60c-d069-4b83-ba92-58bc1c716107)
+*First of 3 oblique sagittal T2 MR presented from lateral to medial shows normal fundal anatomy. The horizontal crista falciformis separates the fundus into the upper and lower portions. The facial nerve is anterosuperior, separated from the superior vestibular nerve by a vertical bony septum called the "Bill bar," which is not resolved. Below the falciform crest are the larger anterior cochlear nerve and posterior inferior vestibular nerve.*
+
+![In the midinternal auditory canal, 4 nerves are clearly identified. The facial nerve is anterosuperior.](06d25c4e-46ee-496e-9c2d-aedc7e9276a1)
+*In the midinternal auditory canal, 4 nerves are clearly identified. The facial nerve is anterosuperior.*
+
+![This image through the porus acusticus reveals the characteristic ball in a catcher's mitt appearance of the facial and vestibulocochlear nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt."](9119a80a-ad8b-4283-b557-644daf21ff7b)
+*This image through the porus acusticus reveals the characteristic ball in a catcher's mitt appearance of the facial and vestibulocochlear nerves. The facial nerve is the "ball" and the vestibulocochlear nerve is the "catcher's mitt."*
+
+
+### 3T T2-SPACE MR
+
+![First of a series of 3 axial slices of a T2 sampling perfection with application-optimized contrasts by using flip angle evolution (T2-SPACE) MR showing the facial nerve.](694bb0c4-bd6a-42b3-a5d6-8dc7642632a6)
+*First of a series of 3 axial slices of a T2 sampling perfection with application-optimized contrasts by using flip angle evolution (T2-SPACE) MR showing the facial nerve.*
+
+![Second in the series shows a more superior axial T2-SPACE MR slice through the facial nerve.](cf5fc791-c8a9-4ef5-9c01-7900e9135e04)
+*Second in the series shows a more superior axial T2-SPACE MR slice through the facial nerve.*
+
+![Third in the series shows a detailed view of an axial T2-SPACE MR slice through the facial nerve. The facial nerve was manually segmented and rendered in 3D in pink. The cochlear and vestibular nerves are also partially visible in green and orange, respectively.](590e5fe8-6f6a-4774-8fa2-e964be1db114)
+*Third in the series shows a detailed view of an axial T2-SPACE MR slice through the facial nerve. The facial nerve was manually segmented and rendered in 3D in pink. The cochlear and vestibular nerves are also partially visible in green and orange, respectively.*
+
+
+### 3T MR
+
+![A 3D surface rendering from T2-SPACE MR of the facial (CNVII) and vestibulocochlear nerve (CNVIII) is shown. The facial nerve was manually segmented and rendered in 3D in pink. The cochlear and vestibular nerves are also partially visible in green and orange, respectively.](4d38eac5-4b10-48b6-ba9c-2e50bfde1349)
+*A 3D surface rendering from T2-SPACE MR of the facial (CNVII) and vestibulocochlear nerve (CNVIII) is shown. The facial nerve was manually segmented and rendered in 3D in pink. The cochlear and vestibular nerves are also partially visible in green and orange, respectively.*
+
+![First of 2 axial sections of a diffusion tensor imaging (DTI) dataset shows the facial nerve along with white matter pathways. The image is colored to indicate orientation, where left-right fibers are colored in red, anterior-posterior fibers are colored in green, and inferior-superior fibers are colored in blue. Note: The facial nerve (CNVII) cannot be visibly discerned from the vestibulocochlear nerve (CNVIII) at this resolution.](cf859cbf-a5ec-4472-89d4-229f7673eb86)
+*First of 2 axial sections of a diffusion tensor imaging (DTI) dataset shows the facial nerve along with white matter pathways. The image is colored to indicate orientation, where left-right fibers are colored in red, anterior-posterior fibers are colored in green, and inferior-superior fibers are colored in blue. Note: The facial nerve (CNVII) cannot be visibly discerned from the vestibulocochlear nerve (CNVIII) at this resolution.*
+
+![Second of 2 axial sections of a DTI dataset showing the facial nerve along with white matter pathways is shown. The facial nerve (CNVII) was modeled using diffusion tractography (orange). Note: The facial nerve (CNVII) cannot be visibly discerned from the vestibulocochlear nerve (CNVIII) at this resolution.](97da5a06-09f2-4987-9998-e8134e05f9bc)
+*Second of 2 axial sections of a DTI dataset showing the facial nerve along with white matter pathways is shown. The facial nerve (CNVII) was modeled using diffusion tractography (orange). Note: The facial nerve (CNVII) cannot be visibly discerned from the vestibulocochlear nerve (CNVIII) at this resolution.*
+

docs_md/articles/facial-nerve-in-temporal-bone_21dccac8-d73d-4ef3-859b-73e013ec15cc.md

@@ -0,0 +1,214 @@
+---
+title: "Facial Nerve in Temporal Bone"
+docid: "21dccac8-d73d-4ef3-859b-73e013ec15cc"
+authors:
+  - key: "b2e6dabb-ee1c-42a4-a332-9f0814c1c607"
+    value: "Surjith Vattoth, MD, FRCR"
+breadcrumbs:
+  -
+    name: "Head and Neck"
+    slug: "head-and-neck"
+    treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+  -
+    name: "Anatomy"
+    slug: "anatomy"
+    treeNodeId: "678bc99d-d43e-45e6-9c8d-9fa5a7648616"
+  -
+    name: "Temporal Bone"
+    slug: "temporal-bone"
+    treeNodeId: "0a35733d-482c-412f-acbc-19b34e7ba61d"
+  -
+    name: "Facial Nerve in Temporal Bone"
+    slug: "facial-nerve-in-temporal-bone"
+    treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "16b49f7c-b13a-4957-a456-28bff373fe31"
+documentVersionId: "0b11b8a3-7805-4dd7-b7ac-f1db6ef4f9d3"
+imageCount: 21
+lastUpdated: "11/28/23"
+pageDescription: "Facial Nerve in Temporal Bone"
+pageKeywords: "Head and Neck, Anatomy, Temporal Bone, Facial Nerve in Temporal Bone"
+pageTitle: "Facial Nerve in Temporal Bone | STATdx"
+enhancedTitle: "Facial Nerve in Temporal Bone"
+type: "ANATOMY"
+breadcrumbs:
+  - "Head and Neck"
+  - "Anatomy"
+  - "Temporal Bone"
+  - "Facial Nerve in Temporal Bone"
+---
+# TERMINOLOGY
+
+- ## Abbreviations
+  
+  
+    - Facial nerve (FN); greater superficial petrosal nerve (GSPN)
+- ## Definitions
+  
+  
+    - FN in temporal bone: Internal auditory canal, labyrinthine, anterior genu, tympanic, posterior genu, & mastoid segments
+
+# IMAGING ANATOMY
+
+- ## Overview
+  
+  
+    - **Internal auditory canal (IAC) segment**: Porus acusticus to IAC fundus; anterosuperior position above crista falciformis
+    - **Labyrinthine segment**: Connects fundal CNVII to geniculate ganglion (anterior genu)
+    - **Anterior genu**: Geniculate ganglion of FN resides here
+          - **GSPN**originates at geniculate ganglion, where **nervus intermedius of Wrisberg (NIW)** joins FN
+    - **Tympanic segment**: Connects anterior to posterior genu
+          - On coronal CT/MR, seen under lateral semicircular canal & above oval window in **medial wall of middle ear**
+          - On more anterior coronal CT/MR, look for snake eyes (snail eyes) appearance of FN labyrinthine segment medially & tympanic segment laterally
+    - **Posterior genu**: Beyond this, FN dips down inferiorly as descending mastoid segment
+    - **Mastoid segment**: Inferiorly directed from posterior genu to exit mastoid temporal bone at **stylomastoid foramen**
+          - Extracranial FN enters parotid gland
+          - Gives off **nerve to stapedius** & **chorda tympani nerve (CTN)**
+          - Runs in posterior wall of ME cavity with air-filled **facial recess** just anterior to FN upper mastoid segment
+          - Bony **pyramidal eminence (PE)** with stapedius muscle at it base located just medial to FN upper mastoid segment
+                  - Do not confuse stapedius muscle for FN
+          - Air-filled **sinus tympani**lies further medially in retrotympanum (RT) & connects to air underneath bony round window niche
+          - Mnemonic for this mediolateral orientation of RT: Sinus ty**m**pani has "**m**"; hence **m**edial; & facia**l** recess has an "**l**"; hence**l**ateral
+          - Sinus tympani can be blindspot at mastoidectomy where cholesteatoma may hide
+- ## Branches of Facial Nerve in Temporal Bone
+  
+  
+    - **GSPN**: Origin from geniculate ganglion (anterior genu)
+          - Travels anteromedially through small hiatus in petrous temporal bone, then in middle cranial fossa floor between layers of dura mater underneath temporal lobe → **foramen lacerum**; at foramen lacerum, GSPN (parasympathetic via NIW) joined by **deep petrosal nerve (DPN)** (sympathetic fibers from internal carotid plexus) to form **vidian nerve**
+          - Evaluate for GSPN schwannoma or perineural tumor spread in these locations
+    - **Nerve to stapedius**: Origin from upper aspect of descending mastoid segment of FN near PE
+          - Motor innervation to stapedius muscle
+    - **CTN**: Origin from mastoid FN
+          - From proximal, mid, or distal mastoid segment, or, rarely, even after exiting stylomastoid foramen
+          - Ascends through **posterior canaliculus of CTN**in posterior wall of middle ear
+                  - Courses in middle ear cavity from posterior to anterior in substance of **tympanic membrane** between mucous & fibrous layers
+                  - Then between upper aspect of handle (manubrium) of malleus & long process of incus, on **medial**side of **upper**part of **handle of malleus**
+                  - Then travels through **anterior canaliculus of CTN** & exits temporal bone into masticator space (MS) through **petrotympanic fissure (Glaserian fissure)** posteromedial to TMJ; in MS, CTN joins lingual nerve (LN) 2 cm below skull base
+          - **Chordal eminence**: Bony prominence on posterior wall of tympanic cavity formed by CTN posterior canaliculus
+          - **Lateral RT** divided by chordal eminence into **facial recess** medially & **lateral tympanic sinus** laterally
+                  - **Styloid eminence** separates lateral RT superiorly from hypotympanum inferiorly
+          - **Chordiculus**: Bony crest between chordal eminence inferolaterally & PE superomedially; origin of tympanic segment of CTN at lateral end of chordiculus
+- ## Anatomy Relationships
+  
+  
+    - **NIW** exits brainstem at pontomedullary junction between pons & inferior cerebellar peduncle lateral to motor root of FN & medial to CNVIII
+    - NIW then courses along with motor root of FN through cerebellopontine angle into anterosuperior IAC quadrant
+    - NIW **joins motor root of FN** near geniculate ganglion
+    - NIW: Somatic sensory, special sensory, & visceral motor (secretomotor) fibers from various brainstem nuclei
+    - **Superior salivatory nucleus (SSN)** in pons: **Parasympathetic** root through NIW → FN → **GSPN** (+ **DPN**, sympathetic) → **vidian nerve** → **pterygopalatine ganglion** in pterygopalatine fossa → **lacrimal gland** & **nasal** glands
+    - SSN in pons: **Parasympathetic** root through NIW → FN → **CTN** → **LN** (CNV3 branch) → **submandibular ganglion** suspended by roots from LN in sublingual space → **submandibular & sublingual salivary glands**
+    - **CTN**also carries afferent **taste** sensation from anterior 2/3rd of tongue via **LN**
+          - LN: Branch of mandibular nerve [V3, trigeminal (CNV) branch]
+    - **Nucleus of tractus solitarius (NTS)** in medulla/lower pons: **Geniculate ganglion** at anterior genu of CNVII in temporal bone contains pseudounipolar cell bodies
+          - Central processes of cell bodies enter gustatory part of NTS, forming special visceral afferent root
+          - Peripheral processes receive **taste** sensation from anterior 2/3rd of **tongue**(**CTN**) & palate (**GSPN**)
+    - **Main sensory nucleus of CNV** in pons: General somatic afferents **sensation** from lateral pinna, posterior external auditory auditory canal & mastoid via **geniculate ganglion**
+    - **Mastoid canaliculus**with**Arnold nerve** [auricular branch of vagus (CNX)] extending laterally from lateral aspect of pars vascularis of jugular foramen toward **tympanomastoid fissure** first **connects** **to descending mastoid segment FN canal** several millimeters above stylomastoid foramen
+          - Then dips inferolaterally toward tympanomastoid fissure (suture) at posterior aspect of external auditory canal
+          - Arnold nerve supplies part of tympanic membrane & external auditory canal
+          - Arnold nerve **cough reflex** on ear stimulation
+                  - When mechanically stimulating ear with finger or ear bud
+
+# CLINICAL IMPLICATIONS
+
+- ## Clinical Importance
+  
+  
+    - Enhancement of geniculate ganglion, tympanic & mastoid segments of CNVII normal on postcontrast T1W MR; can be asymmetric intensity of enhancement on right & left
+          - Secondary to circumneural arteriovenous plexus
+    - **Cisternal**, **IAC**, **labyrinthine**& **parotid** segments **do not**normally **enhance** on MR
+          - Faint enhancement may be seen depending on MR scanner, sequence, & type of contrast used
+          - Be familiar with normal images in different institutions
+    - Always check parotid in peripheral CNVII paralysis
+    - Focal dehiscence of undersurface of tympanic segment FN canal normal variant occurring in as much as 20- 25% of adults, most commonly just above oval window
+          - Important to mention in presurgical temporal bone CT reports to avoid nerve injury during middle ear surgery
+
+ 73481e07-60c3-4a54-b1aa-e4adc388db30
+
+
+## Images
+
+
+### Graphics: Sagittal, Coronal, & Axial
+
+![Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.](images/app.statdx.com_image_thumbnail_71edd785-03d7-4904-8a71-ee56654bcccd_annotated_false_size_900_quality_90_70534c1f125b63d083db4f7bbb4fb72ec4acfcc0.jpg)
+*Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.*
+
+![Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.](images/app.statdx.com_image_thumbnail_71edd785-03d7-4904-8a71-ee56654bcccd_size_174_quality_85_83550ad83c9d3279852bebae9429c8b9077a9e52.jpg)
+*Sagittal graphic shows the medial wall of the middle ear. Note craniocaudal orientation of the lateral semicircular canal (LSCC), facial nerve (tympanic segment), oval window (stapes footplate attaches to oval window), and cochlear promontory (bony bulge covering the basal turn of cochlea). Greater superficial petrosal nerve (GSPN) originates at geniculate ganglion in the anterior genu of the facial nerve, where the nervus intermedius of Wrisberg [(NIW) not shown] joins the facial nerve. Posteroinferiorly, the descending mastoid segment of the facial nerve exits the temporal bone at the stylomastoid foramen on its way to the parotid gland.*
+
+![Coronal graphic shows craniocaudal orientation of LSCC, facial nerve canal (tympanic segment), oval window, & cochlear promontory, a very useful anatomic landmark for evaluating a coronal temporal bone CT. Superior & LSCCs, vestibule, & basal turn of cochlea together form a goose/duck-like appearance on coronal images.](images/app.statdx.com_image_thumbnail_37d31047-1864-40fb-a7a6-7feb50a4e9d2_annotated_false_size_900_quality_90_c9bcb851ae68bce174c17e6b9ba32c77bf464282.jpg)
+*Coronal graphic shows craniocaudal orientation of LSCC, facial nerve canal (tympanic segment), oval window, & cochlear promontory, a very useful anatomic landmark for evaluating a coronal temporal bone CT. Superior & LSCCs, vestibule, & basal turn of cochlea together form a goose/duck-like appearance on coronal images.*
+
+![Axial graphic shows the posterior wall of the mesotympanum with small, air-filled areas (called sinus tympani) medially & facial (CNVII) recess laterally with the bony pyramidal eminence in between.](images/app.statdx.com_image_thumbnail_5d0c9382-ec69-41f4-bdd1-8daf3d272f16_annotated_false_size_900_quality_90_06c42dbb99c5dd5cd8d52f1b423467d2b99515df.jpg)
+*Axial graphic shows the posterior wall of the mesotympanum with small, air-filled areas (called sinus tympani) medially & facial (CNVII) recess laterally with the bony pyramidal eminence in between.*
+
+
+### Coronal Bone CT
+
+![First of 3 coronal reformatted bone CT images from anterior to posterior shows snake eyes (snail eyes) appearance of right facial nerve labyrinthine segment medially lying next to tympanic segment laterally. In the anterior aspect of the internal auditory canal (IAC)/petrous temporal bone, facial nerve (CNVII) lies above with cochlear nerve (CNVIII) lying below (mnemonic: "7-up"/"Coke-down"). The posterior aspect of IAC coronally will have the superior vestibular nerve above with inferior vestibular nerve lying below (both CNVIII); not shown.](images/app.statdx.com_image_thumbnail_bb43c6fe-c14d-4ff3-8a98-8ab5b91691d8_annotated_false_size_900_quality_90_336e02cee76f562d625b13620bf61078a1bcca08.jpg)
+*First of 3 coronal reformatted bone CT images from anterior to posterior shows snake eyes (snail eyes) appearance of right facial nerve labyrinthine segment medially lying next to tympanic segment laterally. In the anterior aspect of the internal auditory canal (IAC)/petrous temporal bone, facial nerve (CNVII) lies above with cochlear nerve (CNVIII) lying below (mnemonic: "7-up"/"Coke-down"). The posterior aspect of IAC coronally will have the superior vestibular nerve above with inferior vestibular nerve lying below (both CNVIII); not shown.*
+
+![CT shows characteristic craniocaudal orientation of the LSCC, facial nerve canal (tympanic segment), oval window, & cochlear promontory. Superior & LSCCs, vestibule, & basal turn of cochlea together form a goose/duck-like appearance. Focal dehiscence of undersurface of tympanic segment facial nerve canal is a normal variant occurring in as many as 20-25% of adults, most commonly just above oval window, but is important to mention in presurgical temporal bone CT reports to avoid nerve injury during middle ear surgery.](images/app.statdx.com_image_thumbnail_b221245a-fbb5-4dfb-9578-90930793d19f_annotated_false_size_900_quality_90_42af176d04f13d1f179f49cb920f99d51ed45dd4.jpg)
+*CT shows characteristic craniocaudal orientation of the LSCC, facial nerve canal (tympanic segment), oval window, & cochlear promontory. Superior & LSCCs, vestibule, & basal turn of cochlea together form a goose/duck-like appearance. Focal dehiscence of undersurface of tympanic segment facial nerve canal is a normal variant occurring in as many as 20-25% of adults, most commonly just above oval window, but is important to mention in presurgical temporal bone CT reports to avoid nerve injury during middle ear surgery.*
+
+![CT shows the posterior genu & descending mastoid segment of the facial nerve with branches.](images/app.statdx.com_image_thumbnail_27c4d177-f644-40e7-9b8a-a810044a9845_annotated_false_size_900_quality_90_63612c8ed23b79e0a3fc3d7fe47d2c84063f2d85.jpg)
+*CT shows the posterior genu & descending mastoid segment of the facial nerve with branches.*
+
+
+### Axial Bone CT
+
+![First of 7 axial temporal bone CT images from top to bottom shows the right facial nerve IAC fundal segment continuing as the labyrinthine segment towards the anterior genu. GSPN originates at the geniculate ganglion in the anterior genu, where NIW joins the facial nerve. GSPN carries preganglionic parasympathetic fibers from superior salivatory nucleus (SSN) in lower dorsal pons (via NIW coming from cerebellopontine angle/IAC; then facial nerve geniculate ganglion in anterior genu; and then the vidian nerve) to supply lacrimal gland and nasal glands through the pterygopalatine ganglion in the pterygopalatine fossa. GSPN also carries sensory afferent taste fibers from the soft palate to nucleus of tractus solitarius (NTS) in medulla/lower pons. GSPN passes through a small hiatus in the petrous temporal bone & then in the middle cranial fossa floor between the 2 layers of dura mater underneath the temporal lobe. Also note the superior vestibular nerve.](images/app.statdx.com_image_thumbnail_657c60db-0d8f-416b-b896-68af35f43261_annotated_false_size_900_quality_90_a8af1a5cd2724644eefdc2cf45e9f3ec4f573393.jpg)
+*First of 7 axial temporal bone CT images from top to bottom shows the right facial nerve IAC fundal segment continuing as the labyrinthine segment towards the anterior genu. GSPN originates at the geniculate ganglion in the anterior genu, where NIW joins the facial nerve. GSPN carries preganglionic parasympathetic fibers from superior salivatory nucleus (SSN) in lower dorsal pons (via NIW coming from cerebellopontine angle/IAC; then facial nerve geniculate ganglion in anterior genu; and then the vidian nerve) to supply lacrimal gland and nasal glands through the pterygopalatine ganglion in the pterygopalatine fossa. GSPN also carries sensory afferent taste fibers from the soft palate to nucleus of tractus solitarius (NTS) in medulla/lower pons. GSPN passes through a small hiatus in the petrous temporal bone & then in the middle cranial fossa floor between the 2 layers of dura mater underneath the temporal lobe. Also note the superior vestibular nerve.*
+
+![Second bone CT shows the tympanic segment of the right facial nerve. Note the inferior vestibular nerve & singular nerve.](images/app.statdx.com_image_thumbnail_54e05147-0a26-43c6-9016-a55775c24a3d_annotated_false_size_900_quality_90_f0e82ee2e04b45716bb69f3b53e92723dc3c9b27.jpg)
+*Second bone CT shows the tympanic segment of the right facial nerve. Note the inferior vestibular nerve & singular nerve.*
+
+![Third bone CT shows the posterior genu of the right facial nerve.](images/app.statdx.com_image_thumbnail_93c44f5a-a6e8-4c3c-9679-bde13a54f523_annotated_false_size_900_quality_90_aec10bd4cd1f5aa97905cc08e52bd260e27ebc20.jpg)
+*Third bone CT shows the posterior genu of the right facial nerve.*
+
+![Fourth bone CT shows the right facial nerve descending the mastoid segment, posteroinferior to posterior genu. Note the stapedius muscle; the tiny nerve to the stapedius arises from the proximal upper descending mastoid segment. Posterior mesotympanum (retrotympanum) has small, air-filled areas (called sinus tympani) medially & facial (CNVII) recess laterally with bony pyramidal eminence in between. Mnemonic for this mediolateral orientation is that sinus tympani has an "m," hence medial; & facial recess has an "l," hence lateral. Sinus tympani can be a blindspot at mastoidectomy where cholesteatoma may hide. Do not mistake the tensor tympani muscle for facial nerve tympanic segment. Chorda tympani nerve enters the anterior wall of the middle ear cavity at the anterior canaliculus of chorda tympani & continues into petrotympanic fissure (Glaserian fissure), which is medial to the TMJ.](images/app.statdx.com_image_thumbnail_b0c5cb00-9db0-4640-975c-ba0c79ad693b_annotated_false_size_900_quality_90_61d31a611509df59b2eab1e425984f48d1e20769.jpg)
+*Fourth bone CT shows the right facial nerve descending the mastoid segment, posteroinferior to posterior genu. Note the stapedius muscle; the tiny nerve to the stapedius arises from the proximal upper descending mastoid segment. Posterior mesotympanum (retrotympanum) has small, air-filled areas (called sinus tympani) medially & facial (CNVII) recess laterally with bony pyramidal eminence in between. Mnemonic for this mediolateral orientation is that sinus tympani has an "m," hence medial; & facial recess has an "l," hence lateral. Sinus tympani can be a blindspot at mastoidectomy where cholesteatoma may hide. Do not mistake the tensor tympani muscle for facial nerve tympanic segment. Chorda tympani nerve enters the anterior wall of the middle ear cavity at the anterior canaliculus of chorda tympani & continues into petrotympanic fissure (Glaserian fissure), which is medial to the TMJ.*
+
+![Image shows descending mastoid segment & posterior canaliculus of the chorda tympani nerve. Note GSPN forming the vidian nerve at the foramen lacerum.](images/app.statdx.com_image_thumbnail_aca0035a-7595-4333-b28f-dfbeac94e5a5_annotated_false_size_900_quality_90_b3008984d4601093e88f687f5d20b469fc506c24.jpg)
+*Image shows descending mastoid segment & posterior canaliculus of the chorda tympani nerve. Note GSPN forming the vidian nerve at the foramen lacerum.*
+
+![Chorda tympani nerve origin from the descending mastoid segment of the right facial nerve is shown.](images/app.statdx.com_image_thumbnail_9523fbb5-8939-4835-9d57-922a6d9367b6_annotated_false_size_900_quality_90_1200f2d48a4baec4f59cfad2b14776673b863400.jpg)
+*Chorda tympani nerve origin from the descending mastoid segment of the right facial nerve is shown.*
+
+
+### Axial Bone CT, Photon-Counting Detector CT, & Graphic
+
+![Last of 7 axial bone CT images shows the right facial nerve exiting the mastoid temporal bone at the stylomastoid foramen on its way to ramify within the parotid gland. Facial nerve perineural tumor spread from parotid malignancy should always be carefully evaluated.](images/app.statdx.com_image_thumbnail_2767dc18-2e4c-4f52-86b6-94cd78e2603b_annotated_false_size_900_quality_90_9d207458a823b0941e3224c72bc2aff2b08fd9c3.jpg)
+*Last of 7 axial bone CT images shows the right facial nerve exiting the mastoid temporal bone at the stylomastoid foramen on its way to ramify within the parotid gland. Facial nerve perineural tumor spread from parotid malignancy should always be carefully evaluated.*
+
+![Axial photon-counting detector CT shows the mastoid canaliculus with the Arnold nerve (auricular branch of vagus [CNX]) originating from the lateral aspect of pars vascularis of the right jugular foramen. Mastoid canaliculus first connects laterally to the descending mastoid segment facial nerve canal a few millimeters above the stylomastoid foramen, then dips inferolaterally toward the tympanomastoid fissure (suture) at the posterior aspect of the external auditory canal (EAC). The Arnold nerve supplies part of the tympanic membrane & EAC & causes Arnold nerve cough reflex when mechanically stimulating the ear with a finger or ear bud.](f539764e-d057-4439-a65e-92b24fe2c03d)
+*Axial photon-counting detector CT shows the mastoid canaliculus with the Arnold nerve (auricular branch of vagus [CNX]) originating from the lateral aspect of pars vascularis of the right jugular foramen. Mastoid canaliculus first connects laterally to the descending mastoid segment facial nerve canal a few millimeters above the stylomastoid foramen, then dips inferolaterally toward the tympanomastoid fissure (suture) at the posterior aspect of the external auditory canal (EAC). The Arnold nerve supplies part of the tympanic membrane & EAC & causes Arnold nerve cough reflex when mechanically stimulating the ear with a finger or ear bud.*
+
+![Axial graphic shows the right mastoid canaliculus with the Arnold nerve [auricular branch of vagus (CNX)] on its way from the lateral aspect of pars vascularis of the jugular foramen toward the descending mastoid segment facial nerve canal.](10f0b222-3ef7-4d59-92e5-6f57eeacbc12)
+*Axial graphic shows the right mastoid canaliculus with the Arnold nerve [auricular branch of vagus (CNX)] on its way from the lateral aspect of pars vascularis of the jugular foramen toward the descending mastoid segment facial nerve canal.*
+
+
+### Chorda Tympani Nerve: Sagittal Graphic, Sagittal Bone CT, & Longitudinal Oblique (Stenver) Bone CT Reformation
+
+![Sagittal graphic shows an internal view of the lateral wall of the middle ear cavity. The chorda tympani nerve originates from the descending mastoid segment of the facial nerve, ascends through the posterior canaliculus of chorda tympani at the posterior wall of the middle ear, courses in the middle ear cavity from posterior to anterior in the substance of the tympanic membrane between mucous & fibrous layers, & then between the upper aspect of the handle (manubrium) of malleus & long process of incus, on the medial side of the upper part of the handle of malleus. It then travels through the anterior canaliculus of chorda tympani & exits the temporal bone into the masticator space through the petrotympanic fissure (Glaserian fissure), which is posteromedial to the TMJ, & joins the lingual nerve 2 cm below the skull base.](196ad546-a000-4b26-ba9f-688556947aa4)
+*Sagittal graphic shows an internal view of the lateral wall of the middle ear cavity. The chorda tympani nerve originates from the descending mastoid segment of the facial nerve, ascends through the posterior canaliculus of chorda tympani at the posterior wall of the middle ear, courses in the middle ear cavity from posterior to anterior in the substance of the tympanic membrane between mucous & fibrous layers, & then between the upper aspect of the handle (manubrium) of malleus & long process of incus, on the medial side of the upper part of the handle of malleus. It then travels through the anterior canaliculus of chorda tympani & exits the temporal bone into the masticator space through the petrotympanic fissure (Glaserian fissure), which is posteromedial to the TMJ, & joins the lingual nerve 2 cm below the skull base.*
+
+![Straight parasagittal bone CT reconstruction perpendicular to the axial CT without any obliquity shows the course of the chorda tympani nerve.](73b52034-5993-416c-9312-506bdfad7fed)
+*Straight parasagittal bone CT reconstruction perpendicular to the axial CT without any obliquity shows the course of the chorda tympani nerve.*
+
+![Longitudinal oblique (Stenver) bone CT of the right ear near the anterior margin of the petrous temporal bony pyramid shows the chorda tympani nerve canal & the nerve itself in the middle ear cavity.](397430d3-55d6-4e6c-947d-e651a5dd4162)
+*Longitudinal oblique (Stenver) bone CT of the right ear near the anterior margin of the petrous temporal bony pyramid shows the chorda tympani nerve canal & the nerve itself in the middle ear cavity.*
+
+
+### Longitudinal Oblique (Stenver) & Transverse Oblique (Pöschl) Bone CT Reformations
+
+![Another longitudinal oblique (Stenver) bone CT more posteriorly shows the entire tympanic segment of the facial nerve. Note the anterior genu, tympanic segment, posterior genu, mastoid segment, & stylomastoid foramen, all seen on this single view. The tympanic segment passes beneath the LSCC.](ff627fe0-223e-4cdd-8998-19fd550d2da5)
+*Another longitudinal oblique (Stenver) bone CT more posteriorly shows the entire tympanic segment of the facial nerve. Note the anterior genu, tympanic segment, posterior genu, mastoid segment, & stylomastoid foramen, all seen on this single view. The tympanic segment passes beneath the LSCC.*
+
+![Further posterior longitudinal oblique (Stenver view) bone CT shows the labyrinthine & tympanic segments of the right facial nerve canal. Note the "2-dot" view of crura of the stapes just before they meet the footplate of the stapes at the oval window.](0783cbd4-f464-483a-807a-7d55985e5b68)
+*Further posterior longitudinal oblique (Stenver view) bone CT shows the labyrinthine & tympanic segments of the right facial nerve canal. Note the "2-dot" view of crura of the stapes just before they meet the footplate of the stapes at the oval window.*
+
+![Transverse oblique (Pöschl) bone CT reformation of the right ear parallel to the long axis of the superior SCC is shown. The image toward the medial aspect of the petrous temporal bone shows the axis of the labyrinthine segment of the facial nerve. When CNVII pathology is present, it is very helpful to have multiple different views of its canal. Transverse oblique (Pöschl) view image set is made in a plane parallel to the axis created by a line through superior SCC, whereas the longitudinal oblique (Stenver) view image set is made in a plane perpendicular to the superior SCC axis.](c5582d04-8569-4eac-8233-bb2105c38bde)
+*Transverse oblique (Pöschl) bone CT reformation of the right ear parallel to the long axis of the superior SCC is shown. The image toward the medial aspect of the petrous temporal bone shows the axis of the labyrinthine segment of the facial nerve. When CNVII pathology is present, it is very helpful to have multiple different views of its canal. Transverse oblique (Pöschl) view image set is made in a plane parallel to the axis created by a line through superior SCC, whereas the longitudinal oblique (Stenver) view image set is made in a plane perpendicular to the superior SCC axis.*
+

docs_md/articles/facial-nerve-lesion-temporal-bone_1428754b-a8ee-48a0-98f8-4faeebf8dbab.md

@@ -0,0 +1,307 @@
+---
+title: "Facial Nerve Lesion, Temporal Bone"
+docid: "1428754b-a8ee-48a0-98f8-4faeebf8dbab"
+authors:
+  - key: "eef2f839-5706-47b9-89c3-60d8315b2b3a"
+    value: "Nicholas A. Koontz, MD"
+breadcrumbs:
+  -
+    name: "Head and Neck"
+    slug: "head-and-neck"
+    treeNodeId: "ed24ed8c-5d57-4629-879b-447b82d2973d"
+  -
+    name: "Differential Diagnosis"
+    slug: "differential-diagnosis"
+    treeNodeId: "40d68862-8975-4dde-ac2b-ebc43ab0fb5c"
+  -
+    name: "Temporal Bone"
+    slug: "temporal-bone"
+    treeNodeId: "2f7dc690-4970-486f-abb6-ed24d99b7a04"
+  -
+    name: "Anatomically Based Differentials"
+    slug: "anatomically-based-differentials"
+    treeNodeId: "115faedf-cc6e-41cd-a155-665ce5b062ee"
+  -
+    name: "Facial Nerve Lesion, Temporal Bone"
+    slug: "facial-nerve-lesion-temporal-bone"
+    treeNodeId: null
+category: "Head and Neck"
+cmeTopicId: "5d11bc10-dd61-4bcd-8c3b-ac0d32054bb1"
+documentVersionId: "61084d95-357b-49d1-8ce1-5fc8c8732500"
+imageCount: 23
+lastUpdated: "08/13/18"
+pageDescription: "Facial Nerve Lesion, Temporal Bone"
+pageKeywords: "Head and Neck, Differential Diagnosis, Temporal Bone, Anatomically Based Differentials, Facial Nerve Lesion, Temporal Bone"
+pageTitle: "Facial Nerve Lesion, Temporal Bone | STATdx"
+enhancedTitle: "Facial Nerve Lesion, Temporal Bone"
+type: "DDX"
+references: true
+breadcrumbs:
+  - "Head and Neck"
+  - "Differential Diagnosis"
+  - "Temporal Bone"
+  - "Anatomically Based Differentials"
+  - "Facial Nerve Lesion, Temporal Bone"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+  
+  
+    - Differential diagnosis considerations
+          - Differential diagnosis built on lesions primary to intratemporal facial nerve
+          - Other lesions included because part of lesion complex is abnormal facial nerve canal
+    - Imaging recommendations for Bell palsy
+          - Routine acute-onset Bell palsy **not** imaged
+          - Image only "atypical" Bell palsy
+    - Imaging recommendations for facial nerve lesion group
+          - Temporal bone (T-bone) CT & high-resolution MR are often complementary
+                  - Particularly true when larger lesions are discovered with either modality
+- ## Helpful Clues for Common Diagnoses
+  
+  
+    - **Normal Facial Nerve Enhancement**
+          - Key facts
+                  - Asymptomatic patient
+                  - Normal imaging finding
+                  - More prominent on 3T MR
+          - Imaging findings
+                  - Bone CT: Normal facial nerve canal
+                  - T1 C+ MR: Area of geniculate ganglion, anterior tympanic segment, & posterior genu of facial nerve may normally enhance
+                  - Symmetric enhancement typical of normal variation
+    - **Bell Palsy**
+          - Key facts
+                  - Acute onset of unilateral peripheral facial nerve paralysis
+                  - > 90% recover & do not need imaging
+                  - MR imaging for "atypical Bell palsy"
+          - Imaging findings
+                  - T-bone CT: Normal facial nerve (CNVII) canal
+                  - T1 C+ MR: Intratemporal facial nerve enhances along entire course
+                  - T1 C+ MR other: Internal auditory canal (IAC) fundal "tuft" enhancement
+                  - Increasing role of 3D-FLAIR
+                            - 3D-FLAIR C-: Bright signal along canalicular CNVII
+                            - 3D-FLAIR C+: Avid enhancement of canalicular CNVII, particularly fundal "tuft"
+                  - High-resolution steady-state free precession T2 should **not** show mass-like nodular enlargement of CNVII
+    - **Temporal Bone Fracture Involving Facial Nerve Canal**
+          - Key facts
+                  - Fracture line crosses facial nerve canal
+                  - Fracture line may be difficult to see
+                            - Multiplanar reconstructions are essential
+                  - High-resolution T-bone CT is criterion standard for imaging but is imperfect tool
+                            - Posterior genu & mastoid segment fractures are challenging to identify on CT; easily overlooked
+          - Imaging findings
+                  - T-bone CT: Fracture may affect geniculate ganglion, tympanic, or mastoid segment of facial nerve
+                  - Transverse fractures affect facial nerve more commonly than longitudinal fractures
+    - **Intratemporal Facial Nerve Perineural Malignancy**
+          - Key facts
+                  - If invasive parotid malignancy found on CT or MR, imaging of stylomastoid foramen & mastoid segment facial nerve is critical
+                  - Always look for perineural malignancy on intratemporal facial nerve
+          - Imaging findings
+                  - T-bone CT: Normal to enlarged mastoid facial nerve canal ± opacification of adjacent mastoid air cells
+                  - T1 C+ MR: Enlarged & asymmetrically enhancing facial nerve segment(s)
+                  - Regardless of modality, scrutinize stylomastoid foramen & evaluate for loss of normal fat plane
+                            - On CT, look for soft tissue replacing normal fat density at stylomastoid foramen
+                            - On MR, look for loss of bright precontrast T1 signal at stylomastoid foramen
+                            - **Caution: Do not fat saturate precontrast T1 MR**
+    - **Facial Nerve Venous Malformation ("Hemangioma")**
+          - Key facts
+                  - May present with acute onset of peripheral facial nerve paralysis
+                  - May be subtle imaging finding early in disease course
+                  - Any focal facial nerve enhancement on MR should be investigated with T-bone CT
+          - Imaging findings
+                  - Most common location: Geniculate fossa
+                  - T-bone CT: "Honeycomb" matrix (50%)
+                  - T1 C+ MR: Geniculate ganglion enhancing mass
+                  - Other MR findings: When large, spreads anteromedially along greater superficial petrosal nerve course
+    - **Facial Nerve Schwannoma**
+          - Key facts
+                  - 50% present with hearing loss
+                  - Facial nerve symptoms may be delayed
+          - Imaging findings
+                  - Most common location: Geniculate fossa
+                  - Often affects multiple contiguous segments of intratemporal facial nerve
+                  - T-bone CT: Expanded, tubular facial nerve canal
+                  - T1 C+ MR: Enhancing mass along facial nerve
+                            - Intramural cystic change possible when large
+- ## Helpful Clues for Less Common Diagnoses
+  
+  
+    - **Oval Window Atresia W****ith Ectopic Facial Nerve**
+          - Key facts
+                  - May be seen with external auditory canal (EAC) atresia or as isolated lesion
+                  - Presents with conductive hearing loss with normal otoscopic exam
+                  - Key diagnosis to make, as facial nerve ectopia may preclude surgery
+                            - If ectopic CNVII not recognized on preoperative imaging, may result in iatrogenic facial nerve injury
+          - Imaging findings
+                  - T-bone CT: Oval window narrowed with bony atresia plate covering window itself
+                  - Tympanic segment facial nerve moves medially from normal location under lateral semicircular canal
+                  - Tympanic segment may be found on superior margin, within, or on inferior margin of atresia plate
+    - **External Auditory Canal Atresia W****ith Ectopic Facial Nerve**
+          - Key facts
+                  - Severity of external ear microtia directly related to degree of EAC-middle ear malformation
+                  - Mastoid segment is most commonly ectopic
+          - Imaging findings
+                  - T-bone CT: EAC is dysplastic with mastoid segment facial nerve anterior to normal location
+                  - Other CT findings: EAC is stenotic or absent
+                  - Small middle ear with ossicle fusion mass ± oval window atresia
+- ## Helpful Clues for Rare Diagnoses
+  
+  
+    - **Prolapsing Facial Nerve I****nto Middle Ear**
+          - Key facts
+                  - Intratemporal facial nerve bordering middle ear cavity may have variable bone covering
+                  - If dehiscence of facial nerve is accompanied by protrusion of nerve into middle ear, there is high risk of injury during surgery
+          - Imaging findings
+                  - T-bone CT: Tympanic segment facial nerve dehiscent ± nerve hanging into middle ear cavity
+                  - Other T-bone CT findings: Facial nerve may appear slightly enlarged when not in bony canal
+    - **Ramsay Hunt Syndrome**
+          - Key facts
+                  - Herpes zoster oticus affects facial nerve ± vestibulocochlear nerve ± inner ear
+                  - EAC vesicles usually precede facial nerve symptoms
+                  - When vesicular rash is delayed or mild, clinical confusion about diagnosis may be present
+          - Imaging findings
+                  - T-bone CT: Facial nerve canal normal
+                  - T1 C+ MR: Enhancing facial nerve in IAC & T-bone
+                  - Increasing role of 3D-FLAIR
+                            - Bright 3D-FLAIR C- inner ear signal & 3D-FLAIR C+ cochlear nerve enhancement more commonly seen in Ramsay Hunt than Bell Palsy
+                            - Enhancement of inner ear structures & cochlear nerve is more variable on T1 C+ MR
+    - **Lyme Borreliosis****of Intratemporal****Facial Nerve**
+          - Key facts
+                  - Bacteria *Borrelia* is tick-borne systemic infection
+                  - May cause acute facial nerve paralysis
+          - Imaging findings
+                  - T-bone CT: Normal facial nerve canal
+                  - T1 C+ MR: Entire intratemporal CNVII enhances
+                  - IAC-CPA CNVII enhancement may also be present
+
+## References
+
+# Selected References
+
+1. [Chen Y et al: Reliability of temporal bone high-resolution CT in patients with facial paralysis in temporal bone fracture. Am J Otolaryngol. 39(2):150-152, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29258690%5Bpmid%5D)
+1. [Kirsch CFE et al: Practical tips for MR imaging of perineural tumor spread. Magn Reson Imaging Clin N Am. 26(1):85-100, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29128008%5Bpmid%5D)
+1. [Kuya J et al: Usefulness of high-resolution 3D multi-sequences for peripheral facial palsy: differentiation between Bell's palsy and Ramsay Hunt syndrome. Otol Neurotol. 38(10):1523-1527, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29135869%5Bpmid%5D)
+1. [Benoit MM et al: Facial nerve hemangiomas: vascular tumors or malformations? Otolaryngol Head Neck Surg. 142(1):108-14, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20096233%5Bpmid%5D)
+1. [Saraiya PV et al: Temporal bone fractures. Emerg Radiol. 16(4):255-65, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=18982367%5Bpmid%5D)
+1. [Okada K et al: Benign mass lesions deep inside the temporal bone: imaging diagnosis for proper management. Acta Otolaryngol Suppl. (559):71-7, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=18340574%5Bpmid%5D)
+1. [Chan EH et al: Facial palsy from temporal bone lesions. Ann Acad Med Singapore. 34(4):322-9, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=15937573%5Bpmid%5D)
+1. [Kress B et al: Bell palsy: quantitative analysis of MR imaging data as a method of predicting outcome. Radiology. 230(2):504-9, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=14699179%5Bpmid%5D)
+1. [Salzman KL et al: Dumbbell schwannomas of the internal auditory canal. AJNR Am J Neuroradiol. 22(7):1368-76, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11498429%5Bpmid%5D)
+1. [Caldemeyer KS et al: Imaging features and clinical significance of perineural spread or extension of head and neck tumors. Radiographics. 18(1):97-110; quiz 147, 1998](http://www.ncbi.nlm.nih.gov/pubmed/?term=9460111%5Bpmid%5D)
+1. [Gebarski SS et al: Enhancement along the normal facial nerve in the facial canal: MR imaging and anatomic correlation. Radiology. 183(2):391-4, 1992](http://www.ncbi.nlm.nih.gov/pubmed/?term=1561339%5Bpmid%5D)
+1. [Parker GD et al: Clinical-radiologic issues in perineural tumor spread of malignant diseases of the extracranial head and neck. Radiographics. 11(3):383-99, 1991](http://www.ncbi.nlm.nih.gov/pubmed/?term=1852933%5Bpmid%5D)
+1. [Curtin HD et al: "Ossifying" hemangiomas of the temporal bone: evaluation with CT. Radiology. 164(3):831-5, 1987](http://www.ncbi.nlm.nih.gov/pubmed/?term=3112865%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![Axial T1 C+ FS MR shows the normal enhancement pattern of the facial nerves. Note mild symmetric enhancement of the geniculate ganglia <img src='img/arrows/WS.png'/> and anterior tympanic segments <img src='img/arrows/WO.png'/> but absent enhancement of the intracanalicular segments <img src='img/arrows/WC.png'/> bilaterally.](images/app.statdx.com_image_45244b52-37f4-4dd9-afe3-8ce34ce05a4f_13ebe745ea1984ef2ba9beda71de5a5c63d40372.jpg)
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ FS MR shows the normal enhancement pattern of the facial nerves. Note mild symmetric enhancement of the geniculate ganglia <img src='img/arrows/WS.png'/> and anterior tympanic segments <img src='img/arrows/WO.png'/> but absent enhancement of the intracanalicular segments <img src='img/arrows/WC.png'/> bilaterally.*
+
+![Axial T1 C+ FS MR shows the normal enhancement pattern of the facial nerves. Note mild symmetric enhancement of the geniculate ganglia <img src='img/arrows/WS.png'/> and anterior tympanic segments <img src='img/arrows/WO.png'/> but absent enhancement of the intracanalicular segments <img src='img/arrows/WC.png'/> bilaterally.](images/app.statdx.com_image_thumbnail_45244b52-37f4-4dd9-afe3-8ce34ce05a4f_size_174_quality_85_e15afc937cd6abc016df21039ef7c6c2e1494f8a.jpg)
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ FS MR shows the normal enhancement pattern of the facial nerves. Note mild symmetric enhancement of the geniculate ganglia <img src='img/arrows/WS.png'/> and anterior tympanic segments <img src='img/arrows/WO.png'/> but absent enhancement of the intracanalicular segments <img src='img/arrows/WC.png'/> bilaterally.*
+
+![Axial T1 C+ MR reveals prominent but normal enhancement of the geniculate ganglion <img src='img/arrows/WS.png'/> and anterior tympanic segment of facial nerve <img src='img/arrows/WO.png'/>.](images/app.statdx.com_image_ee2bcd02-219a-44a2-be61-c84ea0c2a0e3_a6fdb40e0cc3ab291d8f37aff6517617821a1bf7.jpg)
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ MR reveals prominent but normal enhancement of the geniculate ganglion <img src='img/arrows/WS.png'/> and anterior tympanic segment of facial nerve <img src='img/arrows/WO.png'/>.*
+
+![Axial T1 C+ MR reveals prominent but normal enhancement of the geniculate ganglion <img src='img/arrows/WS.png'/> and anterior tympanic segment of facial nerve <img src='img/arrows/WO.png'/>.](images/app.statdx.com_image_thumbnail_ee2bcd02-219a-44a2-be61-c84ea0c2a0e3_size_174_quality_85_9ffca1d3dce3c9e311fb0194a04bc0fef191d48c.jpg)
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ MR reveals prominent but normal enhancement of the geniculate ganglion <img src='img/arrows/WS.png'/> and anterior tympanic segment of facial nerve <img src='img/arrows/WO.png'/>.*
+
+![Axial T1 C+ FS MR in a patient with Bell palsy shows a &quot;tuft&quot; of enhancement at the fundus of the internal auditory canal <img src='img/arrows/WS.png'/> as well as abnormal enhancement along the labyrinthine segment <img src='img/arrows/WO.png'/> and anterior genu <img src='img/arrows/WC.png'/> of facial nerve.](images/app.statdx.com_image_b278ddbb-b71e-4070-b973-812cf399fbf6_79ab8f51d45eac5a6a8adfef960ada1127a7ba9d.jpg)
+**Bell Palsy**
+*Axial T1 C+ FS MR in a patient with Bell palsy shows a &quot;tuft&quot; of enhancement at the fundus of the internal auditory canal <img src='img/arrows/WS.png'/> as well as abnormal enhancement along the labyrinthine segment <img src='img/arrows/WO.png'/> and anterior genu <img src='img/arrows/WC.png'/> of facial nerve.*
+
+![Axial T1 C+ FS MR in a patient with Bell palsy shows a &quot;tuft&quot; of enhancement at the fundus of the internal auditory canal <img src='img/arrows/WS.png'/> as well as abnormal enhancement along the labyrinthine segment <img src='img/arrows/WO.png'/> and anterior genu <img src='img/arrows/WC.png'/> of facial nerve.](images/app.statdx.com_image_thumbnail_b278ddbb-b71e-4070-b973-812cf399fbf6_size_174_quality_85_1b8d4a32a499296947a30adf7076567201bd64e1.jpg)
+**Bell Palsy**
+*Axial T1 C+ FS MR in a patient with Bell palsy shows a &quot;tuft&quot; of enhancement at the fundus of the internal auditory canal <img src='img/arrows/WS.png'/> as well as abnormal enhancement along the labyrinthine segment <img src='img/arrows/WO.png'/> and anterior genu <img src='img/arrows/WC.png'/> of facial nerve.*
+
+![Coronal T1 C+ FS MR in a patient with Bell palsy shows a classic &quot;tuft&quot; of enhancement <img src='img/arrows/WS.png'/> at the fundus of the internal auditory canal above the crista falciformis <img src='img/arrows/WO.png'/>. Note additional enhancement of the tympanic segment <img src='img/arrows/WC.png'/> of facial nerve, which courses below the lateral semicircular canal.](images/app.statdx.com_image_thumbnail_c88c4059-57b5-4220-af6f-0eaee340f275_annotated_true_size_900_quality_90_d673649b54f53ba1022402d47ebb35f02214b5ce.jpg)
+**Bell Palsy**
+*Coronal T1 C+ FS MR in a patient with Bell palsy shows a classic &quot;tuft&quot; of enhancement <img src='img/arrows/WS.png'/> at the fundus of the internal auditory canal above the crista falciformis <img src='img/arrows/WO.png'/>. Note additional enhancement of the tympanic segment <img src='img/arrows/WC.png'/> of facial nerve, which courses below the lateral semicircular canal.*
+
+![Axial bone CT shows a complex, longitudinally oriented fracture <img src='img/arrows/WS.png'/> of the right temporal bone, which traverses the anterior genu of the facial nerve canal <img src='img/arrows/WO.png'/>, resulting in ipsilateral facial paralysis. Note avulsion of the petrous ridge <img src='img/arrows/WC.png'/>.](images/app.statdx.com_image_thumbnail_7bba584d-e498-4281-b109-554f76f27d7b_annotated_true_size_900_quality_90_f181acd0e0c3aff2b6e287f3eff6b4b7f7e72abc.jpg)
+**Temporal Bone Fracture Involving Facial Nerve Canal**
+*Axial bone CT shows a complex, longitudinally oriented fracture <img src='img/arrows/WS.png'/> of the right temporal bone, which traverses the anterior genu of the facial nerve canal <img src='img/arrows/WO.png'/>, resulting in ipsilateral facial paralysis. Note avulsion of the petrous ridge <img src='img/arrows/WC.png'/>.*
+
+![Coronal T1 C+ FS MR shows a small, high, intraparotid adenoid cystic carcinoma <img src='img/arrows/WC.png'/> centered just below the stylomastoid foramen <img src='img/arrows/WO.png'/>. Note avid enhancement of the mastoid segment of the facial nerve <img src='img/arrows/WS.png'/> from perineural tumor spread.](images/app.statdx.com_image_thumbnail_dc41005c-8b98-4fa4-b8f7-077961aeef50_annotated_true_size_900_quality_90_03c7d9eea6b299597acdac62188032e2bd555ca6.jpg)
+**Intratemporal Facial Nerve Perineural Malignancy**
+*Coronal T1 C+ FS MR shows a small, high, intraparotid adenoid cystic carcinoma <img src='img/arrows/WC.png'/> centered just below the stylomastoid foramen <img src='img/arrows/WO.png'/>. Note avid enhancement of the mastoid segment of the facial nerve <img src='img/arrows/WS.png'/> from perineural tumor spread.*
+
+![Axial bone CT shows a permeative expansile lesion <img src='img/arrows/WS.png'/> with a &quot;honeycomb&quot; matrix centered at the anterior genu of the facial nerve canal. Note extension into the widened labyrinthine <img src='img/arrows/WO.png'/> and anterior tympanic <img src='img/arrows/WC.png'/> segments of the facial nerve canal.](4fb1d8f4-90db-4403-90f1-d6ef9b471e23)
+**Facial Nerve Venous Malformation ("Hemangioma")**
+*Axial bone CT shows a permeative expansile lesion <img src='img/arrows/WS.png'/> with a &quot;honeycomb&quot; matrix centered at the anterior genu of the facial nerve canal. Note extension into the widened labyrinthine <img src='img/arrows/WO.png'/> and anterior tympanic <img src='img/arrows/WC.png'/> segments of the facial nerve canal.*
+
+![Axial bone CT demonstrates smooth enlargement of the geniculate fossa <img src='img/arrows/WS.png'/> and the anterior tympanic segment of the facial nerve canal <img src='img/arrows/WO.png'/>, which is typical of facial nerve schwannoma. Note that unlike a venous malformation, no internal matrix is seen.](images/app.statdx.com_image_thumbnail_2f3d99cb-2d28-43c3-a6b8-64217f1b59af_annotated_true_size_900_quality_90_7e4afb4be54c949193d906d74412fc2b476d0071.jpg)
+**Facial Nerve Schwannoma**
+*Axial bone CT demonstrates smooth enlargement of the geniculate fossa <img src='img/arrows/WS.png'/> and the anterior tympanic segment of the facial nerve canal <img src='img/arrows/WO.png'/>, which is typical of facial nerve schwannoma. Note that unlike a venous malformation, no internal matrix is seen.*
+
+![Axial NECT shows a medialized course of the facial nerve tympanic segment <img src='img/arrows/WS.png'/> overlying the oval window, which has a prominent bony atresia plate <img src='img/arrows/WO.png'/> abutting the facial nerve.](1b96784b-21fa-4949-b59a-7c8b8ed21d2c)
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Axial NECT shows a medialized course of the facial nerve tympanic segment <img src='img/arrows/WS.png'/> overlying the oval window, which has a prominent bony atresia plate <img src='img/arrows/WO.png'/> abutting the facial nerve.*
+
+![Coronal bone CT in a child with a complex ear malformation shows an atresia plate at the oval window <img src='img/arrows/WS.png'/> with associated ectopic course of the facial nerve <img src='img/arrows/WO.png'/>, which is positioned more medial than usual along the atresia plate. Note additional hypoplastic lateral semicircular canal <img src='img/arrows/WC.png'/> as well as EAC atresia <img src='img/arrows/BS.png'/> with microtia.](77e82fb5-46b0-432c-afcd-7613f3a4a933)
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Coronal bone CT in a child with a complex ear malformation shows an atresia plate at the oval window <img src='img/arrows/WS.png'/> with associated ectopic course of the facial nerve <img src='img/arrows/WO.png'/>, which is positioned more medial than usual along the atresia plate. Note additional hypoplastic lateral semicircular canal <img src='img/arrows/WC.png'/> as well as EAC atresia <img src='img/arrows/BS.png'/> with microtia.*
+
+![Coronal bone CT in a child with EAC atresia shows an aberrant course of the facial nerve canal <img src='img/arrows/WS.png'/> that is positioned inferolateral to its expected course immediately beneath the lateral semicircular canal <img src='img/arrows/WO.png'/>. A BB marks the expected location of the absent auricle.](d48705f4-d7cc-4639-a8df-c16ffa7ce2f1)
+**External Auditory Canal Atresia With Ectopic Facial Nerve**
+*Coronal bone CT in a child with EAC atresia shows an aberrant course of the facial nerve canal <img src='img/arrows/WS.png'/> that is positioned inferolateral to its expected course immediately beneath the lateral semicircular canal <img src='img/arrows/WO.png'/>. A BB marks the expected location of the absent auricle.*
+
+![Axial bone CT shows a typical case of midtympanic segment facial nerve prolapse into the middle ear cavity <img src='img/arrows/WS.png'/>. The facial nerve is sagging into the oval window niche.](ed442c21-7994-45af-9e61-ba75d3d02485)
+**Prolapsing Facial Nerve Into Middle Ear**
+*Axial bone CT shows a typical case of midtympanic segment facial nerve prolapse into the middle ear cavity <img src='img/arrows/WS.png'/>. The facial nerve is sagging into the oval window niche.*
+
+![Axial T1 C+ FS MR reveals linear internal auditory canal <img src='img/arrows/WS.png'/> and intracochlear <img src='img/arrows/WO.png'/> enhancement, in addition to prominent enhancement of the tympanic segment <img src='img/arrows/WC.png'/> of the facial nerve. The patient had external ear vesicles at the time of imaging.](85ef609b-de3d-4a19-b41e-19d04904a8eb)
+**Ramsay Hunt Syndrome**
+*Axial T1 C+ FS MR reveals linear internal auditory canal <img src='img/arrows/WS.png'/> and intracochlear <img src='img/arrows/WO.png'/> enhancement, in addition to prominent enhancement of the tympanic segment <img src='img/arrows/WC.png'/> of the facial nerve. The patient had external ear vesicles at the time of imaging.*
+
+![Axial T1WI C+ FS MR in a patient with Lyme borreliosis of facial nerve demonstrates intense enhancement of labyrinthine <img src='img/arrows/WS.png'/>, geniculate <img src='img/arrows/WO.png'/>, and anterior tympanic <img src='img/arrows/WC.png'/> segments of the left intratemporal facial nerve. Note that the IAC-CPA segment also enhances faintly.](637f5743-98b8-41d7-8178-9eaa8d724ff1)
+**Lyme Borreliosis of Intratemporal Facial Nerve**
+*Axial T1WI C+ FS MR in a patient with Lyme borreliosis of facial nerve demonstrates intense enhancement of labyrinthine <img src='img/arrows/WS.png'/>, geniculate <img src='img/arrows/WO.png'/>, and anterior tympanic <img src='img/arrows/WC.png'/> segments of the left intratemporal facial nerve. Note that the IAC-CPA segment also enhances faintly.*
+
+
+### Additional Images
+
+![Axial T1 C+ FS MR shows normal enhancement of anterior tympanic segment <img src='img/arrows/WS.png'/> and geniculate ganglion <img src='img/arrows/WO.png'/> portions of intratemporal facial nerve in this asymptomatic patient.](images/app.statdx.com_image_thumbnail_9e6de26b-5d4d-4216-9f16-64a31e238f4d_annotated_true_size_900_quality_90_b99f5717744dcd64f5b6f10821208616e8be9be6.jpg)
+**Normal Facial Nerve Enhancement**
+*Axial T1 C+ FS MR shows normal enhancement of anterior tympanic segment <img src='img/arrows/WS.png'/> and geniculate ganglion <img src='img/arrows/WO.png'/> portions of intratemporal facial nerve in this asymptomatic patient.*
+
+![Axial T1 C+ FS MR reveals an internal auditory canal fundal &quot;tuft&quot; of facial nerve enhancement <img src='img/arrows/WO.png'/> along with enhancement of the labyrinthine segment <img src='img/arrows/WS.png'/> and geniculate ganglion <img src='img/arrows/WC.png'/> in this patient with Bell palsy.](images/app.statdx.com_image_thumbnail_7b24519c-4992-418b-8a4e-694045d55c8f_annotated_true_size_900_quality_90_c6f0047d00b265a2f3dc8caafd8a68b4c697081d.jpg)
+**Bell Palsy**
+*Axial T1 C+ FS MR reveals an internal auditory canal fundal &quot;tuft&quot; of facial nerve enhancement <img src='img/arrows/WO.png'/> along with enhancement of the labyrinthine segment <img src='img/arrows/WS.png'/> and geniculate ganglion <img src='img/arrows/WC.png'/> in this patient with Bell palsy.*
+
+![Axial T1 C+ FS MR shows the midmastoid segment of the facial nerve enhancing avidly <img src='img/arrows/WS.png'/>. A normal mastoid segment never enhances to this degree.](images/app.statdx.com_image_thumbnail_e96609f8-0a48-4a09-bdf4-e475c00df998_annotated_true_size_900_quality_90_29310173a2f80cede2d33b7361e6819ff03fce1c.jpg)
+**Bell Palsy**
+*Axial T1 C+ FS MR shows the midmastoid segment of the facial nerve enhancing avidly <img src='img/arrows/WS.png'/>. A normal mastoid segment never enhances to this degree.*
+
+![Axial bone CT demonstrates a transverse fracture through the inner ear. The fracture line <img src='img/arrows/WS.png'/> passes anteriorly through the labyrinthine segment of the facial nerve canal <img src='img/arrows/WO.png'/>.](images/app.statdx.com_image_thumbnail_566d0bb8-ce72-4440-ac24-052ea0d88827_annotated_true_size_900_quality_90_073f2104d19db189dd5d00345f9b4afcf6189168.jpg)
+**Temporal Bone Fracture Involving Facial Nerve Canal**
+*Axial bone CT demonstrates a transverse fracture through the inner ear. The fracture line <img src='img/arrows/WS.png'/> passes anteriorly through the labyrinthine segment of the facial nerve canal <img src='img/arrows/WO.png'/>.*
+
+![Axial bone CT shows a C-shaped venous malformation of the labyrinthine segment <img src='img/arrows/WO.png'/> and geniculate ganglion <img src='img/arrows/WS.png'/> segments of the facial nerve. The anterior surface of the petrous apex <img src='img/arrows/WC.png'/> is also involved.](1d19693c-eff5-4953-9c98-d5c7a9c75fe6)
+**Facial Nerve Venous Malformation ("Hemangioma")**
+*Axial bone CT shows a C-shaped venous malformation of the labyrinthine segment <img src='img/arrows/WO.png'/> and geniculate ganglion <img src='img/arrows/WS.png'/> segments of the facial nerve. The anterior surface of the petrous apex <img src='img/arrows/WC.png'/> is also involved.*
+
+![Coronal bone CT shows a typical case of oval window atresia with aberrant facial nerve <img src='img/arrows/WS.png'/> overlying the site of the oval window. Any attempt to repair this atresia will result in injury to CNVII.](f1daa9f4-a66c-4032-a1d1-4c5434e6de8a)
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Coronal bone CT shows a typical case of oval window atresia with aberrant facial nerve <img src='img/arrows/WS.png'/> overlying the site of the oval window. Any attempt to repair this atresia will result in injury to CNVII.*
+
+![Axial bone CT demonstrates the tympanic segment of the facial nerve <img src='img/arrows/WS.png'/> overlying the oval window, which has an atresia plate visible <img src='img/arrows/WO.png'/>.](de0a72c9-d3a4-45bb-ba50-f1ac08f74c86)
+**Oval Window Atresia With Ectopic Facial Nerve**
+*Axial bone CT demonstrates the tympanic segment of the facial nerve <img src='img/arrows/WS.png'/> overlying the oval window, which has an atresia plate visible <img src='img/arrows/WO.png'/>.*
+
+![Axial bone CT demonstrates that the mastoid segment of the facial nerve is anterior to its normal location <img src='img/arrows/WS.png'/> as a result of atresia of the EAC.](f7439b89-4207-48aa-8cb4-fc2c0af41599)
+**External Auditory Canal Atresia With Ectopic Facial Nerve**
+*Axial bone CT demonstrates that the mastoid segment of the facial nerve is anterior to its normal location <img src='img/arrows/WS.png'/> as a result of atresia of the EAC.*
+
+![Axial T1 C+ FS MR shows intense enhancement <img src='img/arrows/WS.png'/> of the tympanic segment of the facial nerve in this patient with Lyme borreliosis of intratemporal facial nerve.](655f85ea-3c91-4d6f-93b7-42bca34aedc2)
+**Lyme Borreliosis of Intratemporal Facial Nerve**
+*Axial T1 C+ FS MR shows intense enhancement <img src='img/arrows/WS.png'/> of the tympanic segment of the facial nerve in this patient with Lyme borreliosis of intratemporal facial nerve.*
+

docs_md/articles/groin-mass_160e727f-dabe-4187-aa46-c29625076cc5.md

@@ -0,0 +1,257 @@
+---
+title: "Groin Mass"
+docid: "160e727f-dabe-4187-aa46-c29625076cc5"
+authors:
+  - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+    value: "Siva P. Raman, MD"
+breadcrumbs:
+  -
+    name: "Gastrointestinal"
+    slug: "gastrointestinal"
+    treeNodeId: "b52263f7-5978-4a22-a17d-7260e0033943"
+  -
+    name: "Differential Diagnosis"
+    slug: "differential-diagnosis"
+    treeNodeId: "a0fd80ff-6231-49d3-94b8-ea083449979d"
+  -
+    name: "Abdominal Wall"
+    slug: "abdominal-wall"
+    treeNodeId: "08db01f7-2961-47f7-954d-2a5fca7e707d"
+  -
+    name: "Anatomically Based Differentials"
+    slug: "anatomically-based-differentials"
+    treeNodeId: "1525b44f-9d47-4ff4-8330-693211bd5eb5"
+  -
+    name: "Groin Mass"
+    slug: "groin-mass"
+    treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "be3d839b-85cb-40bb-9883-4885388531ef"
+imageCount: 25
+lastUpdated: "09/13/22"
+pageDescription: "Groin Mass"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Abdominal Wall, Anatomically Based Differentials, Groin Mass"
+pageTitle: "Groin Mass | STATdx"
+enhancedTitle: "Groin Mass"
+type: "DDX"
+references: true
+breadcrumbs:
+  - "Gastrointestinal"
+  - "Differential Diagnosis"
+  - "Abdominal Wall"
+  - "Anatomically Based Differentials"
+  - "Groin Mass"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+  
+  
+    - Although clinical exam may diagnose many common groin masses (particularly hernias), imaging often necessary for accurate diagnosis, particularly with atypical masses
+          - US 1st-line modality for vascular and male reproductive (e.g., cryptorchidism, varicocele) abnormalities
+          - CT and US are best options for diagnosis of groin hernias
+                  - US offers advantage of being able to image patients in different positions (such as standing) or during Valsalva to increase chance of visualizing hernias
+          - CT or MR appropriate for suspected musculoskeletal lesions, such as bursitis or bone tumor
+- ## Helpful Clues for Common Diagnoses
+  
+  
+    - **Inguinal Hernia**
+          - Divided into **direct** or **indirect** subtypes based on relationship to inferior epigastric vessels
+                  - Direct hernias arising anteromedial to inferior epigastric vessels
+                  - Indirect hernias arising superolateral to inferior epigastric vessels
+          - Typically located anterior to horizontal plane of pubic tubercle with no significant mass effect on femoral vein
+          - Hernia sac can contain omental fat, bowel, bladder, appendix, and other pelvic structures
+          - Usually diagnosed on clinical exam, but diagnosis easily confirmed on both CT and US
+    - **Femoral Hernia**
+          - Almost always diagnosed in older women
+          - Extends medial to femoral vein and inferior to inferior epigastric vessels with mass effect on femoral vessels
+          - Hernia sac located posterior and lateral to pubic tubercle
+          - Highest strangulation rate among groin hernias (25-40%)
+    - **Groin Hematoma**
+          - Most often encountered after groin catheterization and should prompt search for underlying pseudoaneurysm or active extravasation, though also commonly seen in setting of inguinal or scrotal surgery and anticoagulation
+          - May demonstrate active extravasation on CECT in setting of active bleeding
+    - **Groin****Pseudoaneurysm**
+          - Most often encountered after groin catheterization (3% of cases following cardiac catheterization)
+          - US demonstrates cystic structure connecting to femoral artery with internal yin-yang biphasic flow
+          - Often treated with compression or thrombin injection
+    - **Groin Arteriovenous Fistula**
+          - Abnormal communication between artery and vein, which is most often iatrogenic and related to groin catheterization
+          - Direct communication between femoral artery and vein may not be readily visible on US, but secondary findings can help make diagnosis (increased diastolic flow in artery, arterialized flow in vein, turbulent flow with soft tissue color bruit artifact)
+    - **Inguinal Lymphadenopathy**
+          - Inguinal regions are common site of lymphadenopathy in many malignancies and systemic disease
+          - Lymph nodes are usually mobile and easily distinguished from hernia based on clinical exam alone, although imaging can easily make distinction in difficult cases
+    - **Varicocele**
+          - Can extend into inguinal canal (as can hydrocele) and may be thought to represent mass on clinical exam
+          - US demonstrates tangle of mildly dilated vessels (≥ 3 mm) with slow flow and enlargement during Valsalva
+          - May be seen on CT with tangle of dilated vessels, which communicate with dilated ipsilateral gonadal vein
+          - Most often found on left side, as isolated right-sided varicocele should raise concern for obstructing mass in abdominal or pelvic cavity
+    - **Spermatic Cord Lipoma**
+          - Can clinically mimic hernia without true hernia being present and frequently mistaken for inguinal hernia on CT/MR
+          - Extremely common incidental finding at surgery (seen in 20-70% of all inguinal hernia repairs)
+          - Fat-containing lesion in inguinal canal **without** any true connection to intraperitoneal fat, though differentiating spermatic cord lipoma from small inguinal hernia on any imaging modality can be extremely difficult to do with accuracy
+    - **Mesh Hernia Repair (Mimic)**
+          - Mesh plugs used during inguinal hernia repair can appear focal and mass-like and potentially mimic lymph node or other mass
+          - Ipsilateral spermatic cord often thickened as well due to surgical manipulation
+- ## Helpful Clues for Less Common Diagnoses
+  
+  
+    - **Cryptorchidism**
+          - Common congenital anomaly found in up to 4% of term male babies, which can be associated with increased risk of infertility and malignancy later in life
+          - Undescended testicle (usually are found in vicinity of groin/inguinal canal) can be palpated on physical exam in vast majority of cases
+          - US or MR are 1st-line imaging modalities with MR offering ability to identify intraabdominal testicle
+    - **Groin Aneurysm**
+          - True atherosclerotic aneurysms of common femoral artery are rare and often associated with aneurysms elsewhere (especially aorta and popliteal arteries)
+    - **Iliopsoas Bursitis**
+          - Focal, teardrop-shaped collection of fluid immediately anterior to hip joint typically associated with hip joint pathology (such as degeneration, infection, etc.)
+    - **Bone Tumor**
+          - Any benign or malignant primary bone tumor arising from pubic rami or hip can present as groin mass with CT and MR best initial modalities for evaluation
+    - **Inguinal Abscess**
+          - Focal, rim-enhancing fluid collection with surrounding stranding and edema in patient with clinical signs and symptoms of infection
+- ## Helpful Clues for Rare Diagnoses
+  
+  
+    - **Canal of Nuck Hydrocele**
+          - Extremely rare condition caused by congenital incomplete obliteration of canal of Nuck (fold of parietal peritoneum that extends into inguinal canal and toward labia majora)
+          - Typically diagnosed in female children (and extremely rarely in female adults) as painless, fluctuant swelling in groin
+          - Unilocular cystic mass in groin extending along inguinal canal toward labia (without any solid or soft tissue component and usually simple in appearance)
+    - **Inguinal Canal Endometriosis**
+          - Endometriosis can rarely extend into inguinal canal (usually on right)
+          - Imaging appearance akin to endometriosis elsewhere with pain groin mass varying with menstrual cycle
+          - Incomplete closure of canal of Nuck may provide pathway for endometriosis to extend into groin
+    - **Liposarcoma**
+          - Fat-containing mass typically with solid, soft tissue components, septations, and other complexity (and with variable amounts of internal fat depending of degree of differentiation)
+          - Primary spermatic cord liposarcomas arise below superficial ring without extension superiorly into peritoneum
+                  - Other primary sarcomas of spermatic cord (leiomyosarcoma, rhabdomyosarcoma, etc.) are also possible but far less common
+          - Retroperitoneal liposarcomas with secondary extension downward into inguinal canal are much less common but can clinically mimic groin hernia
+    - **Metastases to Inguinal Canal**
+          - Metastases to inguinal canal are extraordinary rare, but most common with prostate cancer, pancreatic cancer, melanoma, rhabdomyosarcoma, and pseudomyxoma peritonei
+
+## References
+
+# Selected References
+
+1. [Piga E et al: Imaging modalities for inguinal hernia diagnosis: a systematic review. Hernia. 24(5):917-26, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32328842%5Bpmid%5D)
+1. [Thomas AK et al: Canal of Nuck abnormalities. J Ultrasound Med. 39(2):385-95, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31378959%5Bpmid%5D)
+1. [Yang DM et al: Groin abnormalities: ultrasonographic and clinical findings. Ultrasonography. 39(2):166-77, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31786905%5Bpmid%5D)
+1. [Lechner M et al: Retroperitoneal liposarcoma: a concern in inguinal hernia repair. JSLS. 23(1), 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30700965%5Bpmid%5D)
+1. [Chun EJ: Ultrasonographic evaluation of complications related to transfemoral arterial procedures. Ultrasonography. 37(2):164-73, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29145350%5Bpmid%5D)
+1. [Cabarrus MC et al: From inguinal hernias to spermatic cord lipomas: pearls, pitfalls, and mimics of abdominal and pelvic hernias. Radiographics. 37(7):2063-82, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=29131768%5Bpmid%5D)
+1. [Rhu J et al: Comparison of retroperitoneal liposarcoma extending into the inguinal canal and inguinoscrotal liposarcoma. Can J Surg. 60(6):399-407, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28930047%5Bpmid%5D)
+1. [Park HR et al: Sonographic evaluation of inguinal lesions. Clin Imaging. 40(5):949-55, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27209238%5Bpmid%5D)
+1. [Vagnoni V et al: Inguinal canal tumors of adulthood. Anticancer Res. 33(6):2361-8, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23749883%5Bpmid%5D)
+1. [Siegelman ES et al: MR imaging of endometriosis: ten imaging pearls. Radiographics. 32(6):1675-91, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=23065164%5Bpmid%5D)
+1. [Shadbolt CL et al: Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics. 21 Spec No: S261-71, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11598262%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![Coronal NECT shows a large right inguinal hernia <img src='img/arrows/WC.png'/> containing loops of small bowel without evidence of obstruction. In most cases, inguinal hernias can be palpated and diagnosed clinically.](images/app.statdx.com_image_thumbnail_5ee6e936-a695-4fa3-a38a-0341af092486_annotated_true_size_900_quality_90_bea9a40f43b417f875a0b9f7bedc961b935b75e8.jpg)
+**Inguinal Hernia**
+*Coronal NECT shows a large right inguinal hernia <img src='img/arrows/WC.png'/> containing loops of small bowel without evidence of obstruction. In most cases, inguinal hernias can be palpated and diagnosed clinically.*
+
+![Coronal NECT shows a large right inguinal hernia <img src='img/arrows/WC.png'/> containing loops of small bowel without evidence of obstruction. In most cases, inguinal hernias can be palpated and diagnosed clinically.](images/app.statdx.com_image_thumbnail_5ee6e936-a695-4fa3-a38a-0341af092486_size_174_quality_85_2facd36f2f82deee518b65b7ce55ec819d726a6b.jpg)
+**Inguinal Hernia**
+*Coronal NECT shows a large right inguinal hernia <img src='img/arrows/WC.png'/> containing loops of small bowel without evidence of obstruction. In most cases, inguinal hernias can be palpated and diagnosed clinically.*
+
+![Axial CECT shows the characteristic position of a femoral hernia with a knuckle of bowel <img src='img/arrows/WS.png'/> identified medial to the femoral vessels. Note the characteristic compression of the adjacent femoral vein <img src='img/arrows/WC.png'/>.](images/app.statdx.com_image_thumbnail_86c20f3a-6135-40fb-9f7c-f849d1108e2f_annotated_true_size_900_quality_90_1489571bd312347c4be57448196a0574b564afae.jpg)
+**Femoral Hernia**
+*Axial CECT shows the characteristic position of a femoral hernia with a knuckle of bowel <img src='img/arrows/WS.png'/> identified medial to the femoral vessels. Note the characteristic compression of the adjacent femoral vein <img src='img/arrows/WC.png'/>.*
+
+![Coronal CECT shows a large right groin hematoma with massive active extravasation of contrast <img src='img/arrows/WS.png'/>. This patient had recently undergone a complicated right groin catheterization with subsequent severe blood loss.](images/app.statdx.com_image_thumbnail_69bb2318-7722-4617-89a0-b85801c3d113_annotated_true_size_900_quality_90_21d75e8f4c914b0a842fee1894dbfc57c60c2697.jpg)
+**Groin Hematoma**
+*Coronal CECT shows a large right groin hematoma with massive active extravasation of contrast <img src='img/arrows/WS.png'/>. This patient had recently undergone a complicated right groin catheterization with subsequent severe blood loss.*
+
+![Longitudinal US in a patient with groin swelling after catheterization shows a large, complex hematoma <img src='img/arrows/WS.png'/> with internal echoes and mixed echogenicity.](images/app.statdx.com_image_thumbnail_e92b6c64-f148-41d6-95bb-2053cc2dc041_annotated_true_size_900_quality_90_c9d7b337d1dbdd0a992b99e6745b1e01d127dcd5.jpg)
+**Groin Hematoma**
+*Longitudinal US in a patient with groin swelling after catheterization shows a large, complex hematoma <img src='img/arrows/WS.png'/> with internal echoes and mixed echogenicity.*
+
+![Color Doppler US in a patient who had undergone recent groin catheterization shows the characteristic features of a pseudoaneurysm <img src='img/arrows/WS.png'/> with a yin-yang pattern of internal color flow. Note that the pseudoaneurysm does appear to connect with the adjacent femoral artery <img src='img/arrows/WC.png'/>.](images/app.statdx.com_image_thumbnail_adf73ad5-e2e1-4653-8718-7db0253e7051_annotated_true_size_900_quality_90_4b023759406cd485a168bedc7bc96fa2f3ab962e.jpg)
+**Groin Pseudoaneurysm**
+*Color Doppler US in a patient who had undergone recent groin catheterization shows the characteristic features of a pseudoaneurysm <img src='img/arrows/WS.png'/> with a yin-yang pattern of internal color flow. Note that the pseudoaneurysm does appear to connect with the adjacent femoral artery <img src='img/arrows/WC.png'/>.*
+
+![Axial CECT in a patient with a history of IV drug abuse shows a large, mycotic pseudoaneurysm <img src='img/arrows/WS.png'/> of the right common femoral artery with surrounding fat stranding and edema.](059eb071-7d5b-4fae-9f37-8cef6f0b5143)
+**Groin Pseudoaneurysm**
+*Axial CECT in a patient with a history of IV drug abuse shows a large, mycotic pseudoaneurysm <img src='img/arrows/WS.png'/> of the right common femoral artery with surrounding fat stranding and edema.*
+
+![Axial CECT in a patient with swelling of the right groin after groin catheterization shows asymmetric enlargement and enhancement of the right common femoral vein <img src='img/arrows/WS.png'/>, while the contralateral left femoral vein  <img src='img/arrows/WC.png'/>  is not yet opacified. This constellation of findings should rise strong concern for an AV fistula.](d22a49c2-d34b-4b83-b106-ce9472199617)
+**Groin Arteriovenous Fistula**
+*Axial CECT in a patient with swelling of the right groin after groin catheterization shows asymmetric enlargement and enhancement of the right common femoral vein <img src='img/arrows/WS.png'/>, while the contralateral left femoral vein  <img src='img/arrows/WC.png'/>  is not yet opacified. This constellation of findings should rise strong concern for an AV fistula.*
+
+![Axial CECT shows an enlarged left inguinal lymph node <img src='img/arrows/WC.png'/>, found to represent posttransplant lymphoproliferative disorder in this patient with a history of renal transplant.](cc436e2d-9592-4759-a2c1-141651c5d0c6)
+**Inguinal Lymphadenopathy**
+*Axial CECT shows an enlarged left inguinal lymph node <img src='img/arrows/WC.png'/>, found to represent posttransplant lymphoproliferative disorder in this patient with a history of renal transplant.*
+
+![Sagittal color Doppler US shows a classic tangle of tortuous vessels within the upper part of the scrotum. Flow and vessel dilation are accentuated by Valsalva maneuver, characteristic of a varicocele.](b4b3aa7a-17ea-46fd-9ee1-d664c18b91eb)
+**Varicocele**
+*Sagittal color Doppler US shows a classic tangle of tortuous vessels within the upper part of the scrotum. Flow and vessel dilation are accentuated by Valsalva maneuver, characteristic of a varicocele.*
+
+![Axial CECT shows the characteristic appearance of a mesh plug <img src='img/arrows/WC.png'/> related to prior inguinal hernia repair. This is a classic appearance, which should not be confused for pathology.](8f885a7f-b803-42a7-8435-64fe375ecf77)
+**Mesh Hernia Repair (Mimic)**
+*Axial CECT shows the characteristic appearance of a mesh plug <img src='img/arrows/WC.png'/> related to prior inguinal hernia repair. This is a classic appearance, which should not be confused for pathology.*
+
+![Axial T2 FS MR in a patient with an undescended left testicle shows the T2-bright testicle <img src='img/arrows/WS.png'/> in the left pelvis. MR is the best modality for identifying an undescended testicle with an advantage over US for identifying testicles in the abdominal/pelvic cavities.](c6803ac2-c7e5-4b67-8202-7121e0a23bc0)
+**Cryptorchidism**
+*Axial T2 FS MR in a patient with an undescended left testicle shows the T2-bright testicle <img src='img/arrows/WS.png'/> in the left pelvis. MR is the best modality for identifying an undescended testicle with an advantage over US for identifying testicles in the abdominal/pelvic cavities.*
+
+![Axial CECT shows the classic appearance of iliopsoas bursitis with a fluid collection <img src='img/arrows/WS.png'/> anterior to the right hip displacing the neurovascular bundle <img src='img/arrows/WC.png'/> anteriorly.](bf2d33d7-238b-4ddd-8fc0-85eba5775f82)
+**Iliopsoas Bursitis**
+*Axial CECT shows the classic appearance of iliopsoas bursitis with a fluid collection <img src='img/arrows/WS.png'/> anterior to the right hip displacing the neurovascular bundle <img src='img/arrows/WC.png'/> anteriorly.*
+
+![Axial NECT shows a complex, fat-containing mass <img src='img/arrows/WS.png'/> in the left inguinal canal, found at resection to represent a primary spermatic cord liposarcoma.](78393732-aa77-4f1f-8337-cda1c1566c60)
+**Liposarcoma**
+*Axial NECT shows a complex, fat-containing mass <img src='img/arrows/WS.png'/> in the left inguinal canal, found at resection to represent a primary spermatic cord liposarcoma.*
+
+![Coronal CECT shows a fat-containing mass <img src='img/arrows/WS.png'/> with minimal internal complexity extending from the right lower quadrant into the right inguinal canal. This represents a primary retroperitoneal liposarcoma with secondary extension into the inguinal canal.](a9e9bc1d-746e-4d42-8325-f82c113cb389)
+**Liposarcoma**
+*Coronal CECT shows a fat-containing mass <img src='img/arrows/WS.png'/> with minimal internal complexity extending from the right lower quadrant into the right inguinal canal. This represents a primary retroperitoneal liposarcoma with secondary extension into the inguinal canal.*
+
+
+### Additional Images
+
+![Axial CECT shows bilateral pelvic and inguinal nodal masses <img src='img/arrows/WS.png'/> that were part of generalized disease from non-Hodgkin lymphoma.](75f10054-a17c-4449-9130-42714eeb9fa4)
+**Inguinal Lymphadenopathy**
+*Axial CECT shows bilateral pelvic and inguinal nodal masses <img src='img/arrows/WS.png'/> that were part of generalized disease from non-Hodgkin lymphoma.*
+
+![Axial CECT shows a loculated fluid collection <img src='img/arrows/WS.png'/> that extended along the iliopsoas.](f04cdb3e-c1ce-4673-bd13-2bb57adc0d89)
+**Inguinal Abscess**
+*Axial CECT shows a loculated fluid collection <img src='img/arrows/WS.png'/> that extended along the iliopsoas.*
+
+![Axial NECT shows a heterogeneous, high-attenuation mass <img src='img/arrows/WS.png'/> deep to the femoral vessels and superficial to the femur. This was found to be groin hematoma.](images/app.statdx.com_image_thumbnail_b270785c-d25f-4aca-b751-5b398231739a_annotated_true_size_900_quality_90_5ac98245612a0f157aa91790ef76ee6037c4f8c4.jpg)
+**Groin Hematoma**
+*Axial NECT shows a heterogeneous, high-attenuation mass <img src='img/arrows/WS.png'/> deep to the femoral vessels and superficial to the femur. This was found to be groin hematoma.*
+
+![Sagittal CECT shows a cylindrical fluid collection <img src='img/arrows/WS.png'/> along the right iliopsoas muscle near its insertion on the femur.](7e94f8b2-1265-4ba4-8daa-f92e571e628d)
+**Iliopsoas Bursitis**
+*Sagittal CECT shows a cylindrical fluid collection <img src='img/arrows/WS.png'/> along the right iliopsoas muscle near its insertion on the femur.*
+
+![Axial CECT shows an inguinal hernia <img src='img/arrows/WS.png'/> containing only fat. Hernia is anterior to pubic tubercle, and there is no compression of femoral vessels <img src='img/arrows/WC.png'/>.](images/app.statdx.com_image_thumbnail_bb589af4-a1d9-4bb3-8dc3-cd36ba43caa3_annotated_true_size_900_quality_90_bdbfaa126a6525486baa0f1091268fcbcfa4dfd8.jpg)
+**Inguinal Hernia**
+*Axial CECT shows an inguinal hernia <img src='img/arrows/WS.png'/> containing only fat. Hernia is anterior to pubic tubercle, and there is no compression of femoral vessels <img src='img/arrows/WC.png'/>.*
+
+![Sagittal color Doppler US shows a yin-yang or to-and-fro flow of blood within a spherical common femoral artery pseudoaneurysm, resulting from cardiac catheterization.](6249a162-4640-4737-919e-2702a5160dd1)
+**Groin Pseudoaneurysm**
+*Sagittal color Doppler US shows a yin-yang or to-and-fro flow of blood within a spherical common femoral artery pseudoaneurysm, resulting from cardiac catheterization.*
+
+![Axial CECT shows a groin hematoma <img src='img/arrows/WO.png'/> that resulted from surgical revision of an AV fistula for dialysis. Unlike a pseudoaneurysm, there is no enhancement of the mass.](images/app.statdx.com_image_thumbnail_66eccf8b-fd6d-43e7-94c3-b53ca9000b8f_annotated_true_size_900_quality_90_9d85de46e2f204b55007856080db25846c12eb72.jpg)
+**Groin Hematoma**
+*Axial CECT shows a groin hematoma <img src='img/arrows/WO.png'/> that resulted from surgical revision of an AV fistula for dialysis. Unlike a pseudoaneurysm, there is no enhancement of the mass.*
+
+![Coronal CECT shows a knuckle of small bowel <img src='img/arrows/WO.png'/> that is incarcerated within a femoral hernia, resulting in small bowel obstruction.](images/app.statdx.com_image_thumbnail_754fe116-7c54-4855-8456-1371c71547d5_annotated_true_size_900_quality_90_83cf7abfdd0c91bd702bb5a390adb5ede358c644.jpg)
+**Femoral Hernia**
+*Coronal CECT shows a knuckle of small bowel <img src='img/arrows/WO.png'/> that is incarcerated within a femoral hernia, resulting in small bowel obstruction.*
+
+![Axial CECT shows a small soft tissue mass <img src='img/arrows/WC.png'/> within the right inguinal ring. The right hemiscrotum was small and empty. Normal left spermatic cord <img src='img/arrows/WS.png'/> is noted.](aa1a97f4-ee6d-4766-bfdc-6b6e485915cc)
+**Cryptorchidism**
+*Axial CECT shows a small soft tissue mass <img src='img/arrows/WC.png'/> within the right inguinal ring. The right hemiscrotum was small and empty. Normal left spermatic cord <img src='img/arrows/WS.png'/> is noted.*
+
+![Axial CECT shows a left-sided femoral hernia <img src='img/arrows/WS.png'/>, with the herniated bowel just medial to the femoral vessels.](images/app.statdx.com_image_thumbnail_f554475b-d6cf-4fb1-845e-4c44c06f31c7_annotated_true_size_900_quality_90_2657f141147c4778cfcc41944a5a574a57cced28.jpg)
+**Femoral Hernia**
+*Axial CECT shows a left-sided femoral hernia <img src='img/arrows/WS.png'/>, with the herniated bowel just medial to the femoral vessels.*
+
+![Axial CECT shows a cylindrical fluid collection <img src='img/arrows/WS.png'/> along the right iliopsoas muscle, near its insertion on the femur.](626904ce-7c54-406b-9df0-48732dab3ded)
+**Iliopsoas Bursitis**
+*Axial CECT shows a cylindrical fluid collection <img src='img/arrows/WS.png'/> along the right iliopsoas muscle, near its insertion on the femur.*
+