 Hello everyone, I am Dr. Tanvi, third year resident from Saiyan Hospital. So the topic for my paper presentation is about head and neck Paragangalumas. I will be presenting this paper in two forms. First, I have a case report which is a very interesting case report on head and neck Paragangalumas followed by a discussion on the same. So in our day-to-day radiological practice, we encounter a lot of neck masses. Some are benign and some are malignant. Even after extensive cross-sectional imaging in many of them, we always require a biopsy or that is the histopathological diagnosis is always required. But Paragangalumas is one of its kind of tumor where cross-sectional imaging is itself enough and we generally don't need or don't perform a biopsy unless we want to perform some immunohistochemistry for the same. So CT scan or cross-sectional imaging is not only superior, but it is always preferred in the cases of Paragangalumas and that's what make this tumor a special kind of tumor. So let's proceed with my case. Aim an introduction of my paper will be to highlight distinctive imaging features of Paragangalumas using a wide range of imaging modalities and to emphasize importance of radiological investigations in the case of multifocal head and neck Paragangalumas with an interesting case report as I have already told. The methods which I have used for this particular paper are basically I have performed USG using G healthcare USG machine that is logic P9 machine and 12 hertz linear probe SC. And the CT neck scan was done using a Toshiba 160 slice scanner. So few days ago we had a patient who presented to ENT department. He was a 68 year old male and his main symptoms were bilateral neck swellings which were progressively increasing since last five years. He was a hawker by profession so the thing which was disturbing for him was not only the neck swellings but change in his voice or the harshness of his voice. ENT people further evaluated the patient and the patient gave no history of headache, palpitation, fever, cough, weight loss. He did not had any hearing related complaints or tinnitus or facial deviation as well. On examination they found out there were masses in the neck which were bilateral and most of them are anterior to sternocleidomesteroids at cervical level 2 and 3. This masses were non-pulsitile, they were tender and they were discreet as well as mobile. Another important finding which they found or which they like highlighted was on palpation the neck swellings it triggered cough reflex in the patient. So as a first investigation they referred patient to us for USG. So USG neck was done and these are some USG images. So here this lesion which you can appreciate this is in the right cervical region. I just seen at the bifurcation of right common kerotid artery and there is playing of right ECN-ICA which you can appreciate on this and this is the very important or characteristic finding this is known as Liar Sign. As we moved more quietly with our USG Pro we could appreciate one more lesion which was just along the course of right ICN. So similarly on the left side we could appreciate a lesion which was between external and internal kerotid artery and another lesion which was not well appreciated or I can say it was a ill-defined thing but certainly there was a lesion again along right ICN. So we had these two lesions, supposedly these two lesions were kerotid body tumors and the lesions which were further superior to these two we suspected it to be glomus vagalli. So to further characterize these lesions we went ahead with cross-sectional imaging that is the CT scan which we performed of neck. So these are some CT images. Here these are the plane images, non-contrast phase images. So here you can see these two masses which were labulated, soft tissue density lesions and they are at the bilateral cervical region, mainly in the region of kerotid body. These two masses which you can see, then another mass was appreciated at the skull base on the left side at the region of juggler bulb. In this image you can see this mass it is in the left paratrochial region. Further the contrast imaging was performed and again now you can see intensely enhancing masses and their relation with the vessels. These two kerotid body tumors again this mass which is in the left paratrochial region and two superior masses which were in relation to ICA but they were much more superior than the original masses. Here you can appreciate the relation with the vessel very well. These are bilateral ICA which are displaced anteriorly and bilateral ICA which are displaced quite posteriorly because of these lesions which are seen encasing these vessels. This is the bifurcation of CCA and again at the bifurcation you can see this tumor. These I have some 3D images again just to show the relation of these masses with the vessels. So this is the bifurcation of CCA, right common kerotid and this is the mass which is kerotid body tumor on the right side. Superior to that again you can see this lesion. This is the IHAV internal juggler vein and again this is the bifurcation of common kerotid. You can see this mass and again superiorly we can see this mass. The mass which was appreciated at the skull base it had a similar characteristic with all the previous glomus vegeale as well as kerotid body tumors and this mass was seen at the juggler bulb. It was extending into juggler foramen with juggler proximal IHAV and juggler bulb not seen separately from this particular mass. It was seen causing bone destruction at the skull base of left-sided vitreous apex as well as left juggler spine as well as posterior wall of left kerotid canal. These are the images representing the same mass. Then this small lesion was also appreciated in the left pre-vascular space. It was actually above the origin of common kerotid and left subclavian artery and it was in the left paratrochial region just about taking the left thyroid gland. So apart from all these masses, two very conclusive findings which almost sought this case for us were these. So here you can see this is the tongue. So on left side there is moderate to severe atrophy of the intrinsic tongue muscles. We attributed this to this lesion. As this lesion that is glomus surgulari, it was seen causing destruction of hypoglossal canal thus because of the nerve compression there was a hemiatrophy of the tongue muscles. Then again here in this sections, if you can see left vocal cords, they really are paramedial in location that is there is actually left vocal cord paralysis and we attributed this to this culprit as this lesion was just in the left paratrochial region and it must be causing compression of left recurrent laryngeal nerve. So on the basis of USG and CT, the diagnosis of multiple paraganglioma was established. So in this patient, in this single patient, we could see almost every type of hedonic paraganglioma that is we encountered bilateral kerotid body tumors, bilateral glomus vegeale, left glomus jugulare and left paratrochial space tumor as well. So the evaluation of symptoms was also done by using the cross-sectional imaging. Paragangliomas as the name suggests, they are arising from the paragangliome cell, they are also known as glomus tumors and paraganglioma cells, paragangliome cells are nothing but the extraadrenal neuroendocrine cells. So what is the main thing about hedonic paragangliomas? This hedonic paragangliomas are non-secretary tumors, they won't secret any ketocorylamines. The symptoms because of this paragangliomas are mainly related to pressure effects, that is the pressure effect which they cause on the cranial nerves and that will lead to different symptoms in different, different patient. Just as we encountered in our patient. Now most of the paragangliomas are solitary. It is difficult to find multifocal or multiple paragangliomas. Our case was important, our case report was important as we can see multiple paragangliomas in a single patient. Usually multiple paragangliomas are associated with some other neuroendocrine disorders or some other family varieties of syndromes, just like neurofibromatosis, von Hippel Down syndrome, paragangliomas syndrome or multiple neuroendocrine nyoblaces, we meant two syndromes. So for our patient also further syndromic evaluation was done using his screening USG as well as X-ray. We evaluated his medical history, past surgical history, family history but it was all inconclusive in this case. As I said earlier only, biopsy is generally avoided in this patients because of high vascularity of the tumor and the treatment of choice for this patients will be surgical resection always. MRI is also very sensitive because it can differentiate the soft tissue resolution and it can differentiate the paragangliomas from other neck masses and we can have a soft tissue differentiation better with MRI rather than CTs. Now we haven't performed an MRI in this patient but this is just a sample MRI image to show how the paragangliomas will actually look on MRI. The initial appearance which we have for paragangliomas on MRI is salt and pepper appearance that is salt is the white thing, pepper is the black thing so some white and black spots or white or black areas we will see in paragangliomas. So what are these white and black dots or spots or areas? White areas are basically intertumoral hemorrhages which will appear hyper intense on T1 as well as T2-rated images and black areas that is the pepper. They are nothing but flow voids because of the high vascularity which we can encounter on T2-rated images. So that makes paraganglioma appear salt and pepper like on MRI. This is just to show the common locations of head and neck paraganglioma. We already know carotid body and vagus nerve, juggler foramen these are the common locations. Juggler tympanic paraganglioma can occur just tympanic paraganglioma can occur that is called as glomus tympanica. Some uncommon locations like sila tarsica and cavernastina these are also to look for when we encountered head and neck paraganglioma. So this classification we have, this classification is not so important for radiology people but it is important with surgical point of view because as the grade increases there is increased risk for the surgery and there is increased need for the vascular reconstruction in the patients. So as per chameleon classification type one is the paraganglioma which is in the carotid body but it is not involving ICA or ECA it is not involving the carotid vessels. Type two is it is getting adherent to the vessels. Type three is it is causing encasement of the vessel and one more type 3B is added in the modified chameleons classification where you can see the paragangliomas and they are getting infiltrated by, they are infiltrating the vessel walls. This is the basic crux of my paper that is the key points of head and neck paragangliomas. So as we have already seen carotid body tumors they will cause playing of internal and external carotid arteries but glomus vegeale, glomus vegeale they are along the vagal trunk and vagal trunk is posterior lateral to the carotid vessels. So they will just displace the carotid vessels and they are medial. They will cause playing of internal jugular vein with the carotid vessels. Then we have glomus jugulari which are the skull based tumor and they cause permeative destruction. They can extend to cerebellum and angle and in the right carotid space as well. Then we have glomus tympanicum these are in the middle ear and they are in the cochlear plomondry. Common findings of these are all these will be highly vascular avidly enhancing. They have sometimes tendency for bilaterality or multifocality. They can be metastasis there can be metastasis associated and always on the PET scan or MIBG scan or optite strand they will show a high uptake. These are my references. Thank you.