Clinical Radiology xxx (2016) e1ee12

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Clinical Radiology
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Pictorial Review

Classic signs in head and neck imaging q

N.A. Koontz a,b,*, T.A. Seltman a, S.F. Kralik a, K.M. Mosier a,
H.R. Harnsberger b
a
Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 North University Blvd,
Rm 0663, Indianapolis, IN 46202, USA
b
Department of Radiology, University of Utah Health Sciences Center, 30 North 1900 East #1A071, Salt Lake City, UT
84132-2140, USA

article information
Radiologists have long relied upon the use of metaphoric imaging signs to attribute meaning to
Article history: disease or anatomy-specific imaging patterns encountered in clinical imaging. Teachers of
Received 9 July 2016 radiology often employ the use of such signs to help learners rapidly identify the typical
Received in revised form appearance of various pathologies. Head and neck (H&N) imaging is no exception, and as a
9 July 2016 specialty that deals with uncommon pathologies and complex anatomy, learners and prac-
Accepted 8 September 2016 tising radiologists alike may benefit from this simplistic, pattern-based approach. In this re-
view, we present a compendium of classic imaging signs of H&N lesions, including signs
related to traumatic, infectious, neoplastic, congenital, and inflammatory aetiologies found
throughout the spectrum of H&N sites (temporal bones, orbits, paranasal sinuses, larynx,
salivary glands, and neck soft tissues). Additionally, we identify potential pitfalls and detail
critical clinical ramifications related to the rapid and accurate diagnosis of these pathologies.
© 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction harnessing man’s innate ability to extract pattern infor-

Radiologists have long relied upon the use of
metaphoric imaging signs to attribute meaning to disease
or anatomy- specific imaging patterns encountered in
clinical practice. Dating back to 1918, when Crane first
reported the “inverted comma” sign1 on pulmonary
radiographs, radiologists have taken advantage of
fortuitous similarities between certain imaging findings
and the appearance of common daily ob- jects or patterns
to rapidly recall certain diagnoses, thus
q This manuscript was presented, in part, as an accepted electronic educational
exhibit at the American Society of Head and Neck Radiology 49 th Annual Meeting,
Naples, Florida in September 2015.
* Guarantor and correspondent: N. A. Koontz, Department of Radiology
and Imaging Sciences, Indiana University School of Medicine, 550 North
University Blvd, Rm 0663, Indianapolis, IN 46202, USA. Tel.: þ1 (317) 963
7195; fax: þ1 (317) 715 6474.
E-mail address: nakoontz@iupui.edu (N.A. Koontz).
mation from a visual stimulus and rapidly match it to a
specific, finite entity recalled from memory. Such instanta-
neous processing of pattern-based visual cues to decipher a
specific, pathognomonic entity is often referred to in the
medical community as the “Aunt Minnie” phenomenon.2,3
Although its mechanism is not well understood, it may
have roots in the Gestalt theory of perception and hold
significance for radiology learners.4,5
Due to the complex anatomy and uncommon
pathologies encountered in clinical practice, head and neck
(H&N) im- aging has historically been viewed with
trepidation by learners, who may benefit from a simplified,
pattern-based approach to learning. As such, we propose
that both radi- ology trainees and practising radiologists
may be greatly aided by familiarity with several imaging
signs that have been attributed to H&N lesions. In this
review, we present a compendium of these classic imaging
signs, highlight the

http://dx.doi.org/10.1016/j.crad.2016.09.006
0009-9260/© 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Koontz NA, et al., Classic signs in head and neck imaging, Clinical Radiology (2016),
http://dx.doi.org/10.1016/ j.crad.2016.09.006
e2 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12
salient imaging findings, identify potential pitfalls, and
detail important clinical ramifications. Images were retro-
spectively obtained through review of the electronic
medical records and picture archiving and communication
system (PACS), maintaining compliance with the Health
Insurance Portability and Accountability Act (HIPAA) and
policies of the institutional review boards at the authors’
institutions. This research did not receive any specific grant
from funding agencies in the public, commercial, or not-
for-profit sectors. All photos and artwork are courtesy of
the authors’ personal collections or open-source internet
collections.
Temporal bones
“Broken heart” and “Y” signs of incudomalleolar
disarticulation
Trauma, typically blunt injury, may result in disarticu-
lation of the incudomalleolar joint, which manifests as
subtle joint widening and lateral displacement of the
incus.6,7 Patients present with conductive hearing loss on
the affected side. While this can be seen in the axial plane,
conspicuity of the finding is increased when viewed in
coronal reconstruction (Fig 1), which has previously
described as the “Y” sign in the earenoseethroat (ENT)
literature8 and by the pithy moniker of the “broken heart”
sign by neuroradiologists.9 Incudomalleolar disarticulation
has been reported as the one of the most common ossicular
chain injuries,6,7 thus multiplanar imaging is advised to
scrutinise for subtle incudomalleolar disarticulation.
“Ice-cream cone” sign of vestibular schwannoma
Schwannomas are a commonly encountered nerve
sheath tumour, which grow eccentric to the nerve of
origin.10 On high-resolution magnetic resonance imaging
(MRI) of
Figure 1 “Broken Heart” and “Y” signs of incudomalleolar disarticulation. (a) Coronal non-contrast enhanced CT shows widening of the incu-
domalleolar joint (white solid arrow) with lateral displacement of the short process of the incus (white open arrow) relative to the head of the
malleus (white arrowhead). (b) This configuration of the ossicles observed on coronal CT has been likened to the appearance of a “broken heart”
the temporal bones, vestibular schwannomas may
resemble an “ice-cream cone” with the bulbous extension
of tumour within the cerebellopontine angle (CPA)
resembling the ice- cream sitting upon a cone of tumour
within the internal auditory canal (IAC; Fig 2). Vestibular
schwannomas are the most common mass involving the
CPA and IAC,11 as well as the most common mass
accounting for sensorineural hear- ing loss.12 The vast
majority of vestibular schwannomas are unilateral and
sporadic, but the presence of bilateral vestibular
schwannomas is essentially pathognomonic for
neurofibromatosis type 2 (NF2).13
“Corkscrew cochlea” sign of X-linked stapes gusher
X-linked stapes gusher is a rare congenital aetiology for
mixed conductive and profound sensorineural hearing loss
due to POU3F4 gene mutation.14 At temporal bone
computed tomography (CT), these patients demonstrate a
characteristic “corkscrew” configuration of the cochlea
(Fig 3) due to absence of the interscalar septum and mod-
iolus, as well as a bulbous configuration of the lateral in-
ternal auditory canal with deficient lamina cribrosa.15 This
allows communication between subarachnoid cerebrospi-
nal fluid (CSF) and cochlear perilymph, which may result in
a perilympheCSF gusher and perilymph fistula if stape-
dectomy or cochleostomy is attempted.
Orbits
“Tram-track” sign of optic nerve sheath meningioma
Optic nerve sheath meningiomas are the most common
tumour of the optic nerve sheath, but only account for
around 2% of orbital tumours.16,17 At MRI, they character-
istically demonstrate linear, often parallel enhancement
along the periphery of the nerve sheath due to spread of
or “Y”.
 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12 e3

Figure 2 “Ice-cream cone” sign of vestibular schwannoma. (a) Axial T1 SPGR post-contrast image shows an avidly enhancing mass (white solid
arrow) extending from the CPA to the fundus of the IAC. (b) When large enough, vestibular schwannomas viewed in the axial plane resemble an
“ice-cream cone” with the bulbous extension of tumour in the CPA resembling the ice-cream sitting upon a cone of tumour in the IAC.

Figure 3 “Corkscrew cochlea” sign of X-linked stapes gusher. (a) Axial non-contrast CT of the temporal bones demonstrates an abnormal
morphology of the cochlea (white solid arrow) with absent interscalar septum and modiolus, as well as a bulbous configuration of the lateral
internal auditory canal (white open arrow). (b) This abnormal cochlear configuration resembles a corkscrew and is typical of X-linked stapes
gusher.

tumour in a vector paralleling the sheath 18; however,

the “tram-track” pattern of enhancement on MRI is not
specific to optic nerve sheath meningioma, and similar
enhancement can also be seen with idiopathic orbital
inflammatory disease, optic neuritis, orbital sarcoidosis,
lymphoproliferative disease, ErdheimeChester, and un-
commonly with metastases.19 Although MRI is the
preferred imaging technique, CT is complimentary and may
demon- strate “tram-track” calcification specific to
meningioma, confirming the diagnosis20 (Fig 4).
“Martini glass” sign of persistent hyperplastic primary
vitreous
incomplete regression of the embryonic ocular blood sup-
ply, resulting in leukocoria, impaired vision, micro-
phthalmia, and retinal detachment.21e23 At MRI, this
manifests as abnormal, triangular-shaped retrolenticular
tissue that resembles a “martini glass” (Fig 5). PHPV lacks
calcification often seen in retinoblastoma, which can be a
helpful discriminator.24
Paranasal sinuses
“Convoluted cerebriform pattern” of inverted papilloma

Persistent hyperplastic primary vitreous (PHPV) is a Inverted papilloma is an uncommon benign epithelial
congenital developmental malformation of the eye due to tumour of the sinonasal tract.25 At MRI, they demonstrate a
characteristic gently lobulate morphology resembling the
e4 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12

Figure 4 “Tram-track” sign of optic nerve sheath meningioma. (a) Axial post-contrast T1-weighted fat-saturated image shows parallel linear
enhancement along the orbital segment of the optic nerve sheath (white solid arrows), which resembles the parallel orientation of light rail or
train tracks (Powell/Hyde cable car line, San Francisco, California). This pattern of enhancement is sensitive, but not speci fic for optic nerve
sheath meningioma. (b) Non-contrast enhanced CT reveals “tram-track” calcification of the optic nerve sheath (white open arrows), which, in
comparison, is highly specific for meningioma.

Figure 5 “Martini glass” sign of PHPV. (a) Axial fat-saturated T2-weighted image demonstrates a small right globe with abnormal triangular-
shaped retrolenticular soft tissue (white open arrow) in a child with PHPV. (b) This configuration of the retrolenticular soft tissue resembles
the shape of a martini glass.

gyral and sulcal pattern of the brain (Fig 6). This Most
“convoluted cerebriform pattern” has a reported sensitivity
of 100% and specificity of 87% for diagnosing inverted
papilloma, and focal loss of this pattern within an inverted
papilloma may signal the presence of a coexistent
malignancy.25 Despite a benign histopathology, inverted
papilloma is locally aggressive with high rate of recurrence,
multicentricity, and can have coexistent squamous cell
carcinoma.26,27 Most commonly found at the lateral nasal
wall near the middle turbinate and maxillary ostium,
inverted papilloma can also be found within the paranasal
sinuses.25,28

“Bow” and “antral” signs of juvenile nasopharyngeal

angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is a rare,

benign neoplasm thought to originate from a vascular
nidus in the posterolateral wall of the nasal cavity at the
sphe- nopalatine foramen margin or the pterygoid canal.29
commonly seen in adolescent males, patients present
with painless nasal blockage and epistaxis. On imaging,
including cross-sectional and radiographs, anterior
bowing of the posterior wall of the maxillary antrum
may be observed, the so-called “bow” or “antral” signs30
(Fig 7). Radiologists must keep in mind that this sign is
only indicative of a relatively slow-growing mass that
results in osseous remodelling of the posterior wall of
the maxillary sinus, thus it is not specific for JNA.
Differential considerations include sino- nasal polyp,
nerve sheath tumour, adenoid hypertrophy, lymphoma,
and rhabdomyosarcoma.

“Black turbinate” sign of invasive fungal sinusitis

Invasive fungal sinusitis is a potentially fatal, rapidly

progressive transmucosal sinus infection that occurs in
immunocompromised patients with neutropenia,
including diabetics with functional neutropenia.31,32 The
nasal cavity is typically the primary site of infection,
involving the middle
 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12 e5

Figure 6 “Convoluted cerebriform pattern” of inverted papilloma. (a) Axial T1 SPGR post-contrast image demonstrates a large, heterogeneously
enhancing mass (white solid arrow) centred in the right frontal sinus. (b) This lobular morphology with repetitive curvilinear striations re-
sembles the surface topography of the brain and is specific for inverted papilloma.

Figure 7 “Bow” sign of JNA. (a) Axial CT of the paranasal sinuses demonstrates a large soft-tissue mass (white solid arrow) expanding the right
pterygopalatine fossa and extending into the nasal cavity via a widened sphenopalatine foramen (white arrowhead). Note relatively benign
remodelling of the posterior wall of the maxillary sinus (white open arrow). (b) This pattern of anterior displacement of the antrum resembles
the shape of a bow and is suggestive of JNA or other slow-growing retroantral mass.

turbinate in approximately two-thirds of patients. 33 Trans-

mucosal hyphal invasion results in vascular compromise,
yielding tissue infarction and dry gangrene, which corre-
sponds with areas of loss of contrast enhancement in the
sinonasal mucosa, which ordinarily enhances avidly. The
so- called “black turbinate” sign identifies areas of invaded
non- viable mucosa, which correspond to the black eschar
seen on endoscopy (Fig 8). Due to the significant morbidity
and mortality, this is truly a “can’t miss” diagnosis.
Larynx
“Spinnaker sail” sign of vocal cord paralysis
The vocal cords receive innervation from the vagus
nerve, and a lesion injuring it anywhere from the origin
nucleus in the medulla to the recurrent laryngeal nerve
may result in vocal cord paralysis. Aetiologies are sundry,
including trauma, neoplasm, ischaemia, iatrogenic, toxic,
and idiopathic causes.34 At CT, patients with vocal cord
paralysis reliably demonstrate dilatation of the ipsilateral
pyriform sinus, medialisation, and thickening of the ipsi-
lateral aryepiglottic fold, and dilatation of the ipsilateral
laryngeal ventricle, the latter resembling the appearance of
a flying spinnaker sail34 (Fig 9). When encountered on im-
aging, vocal cord paralysis must be considered pathological
and warrants an exhaustive search for inciting causes.35
“Thumb” sign of epiglottitis
Epiglottitis is a critical diagnosis that radiologists must
be able to diagnose rapidly and accurately, as life-
e6 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12

Figure 8 “Black turbinate” sign of invasive fungal sinusitis. (a) Axial fat-saturated contrast-enhanced T1-weighted image in a diabetic patient
with facial pain demonstrates loss of mucosal contrast enhancement of the left middle turbinate (white open arrow) and medial wall of the left
maxillary sinus, which corresponds with the black eschar of necrotic tissue (b) observed on nasal endoscopy (image courtesy of Richard H.
Wiggins, III, MD, University of Utah Health Sciences Center). Normally, the mucosa of the nasal cavity and paranasal sinuses should enhance
avidly (white solid arrows) and in neutropenic or functionally neutropenic patients, areas of loss of contrast enhancement are highly concerning
for invasive fungal sinusitis.

Figure 9 “Spinnaker sail” sign of vocal cord paralysis. (a) Axial contrast-enhanced CT of the neck in a young man with left vocal cord paralysis
due to an upper mediastinal mass demonstrates marked dilatation of the ipsilateral laryngeal ventricle (white solid arrow), which resembles the
appearance of a flying spinnaker sail (b). In this case, the spinnaker sails are the striped sails.

threatening airway compromise is possible. 36 On lateral

radiographs of the neck, epiglottitis manifests as soft-tissue
swelling of the supraglottic larynx with the epiglottis
resembling a “thumb” in approximately 80% of cases 37
(Fig 10). Patients present with high fever, sore throat, and
difficulty swallowing, which may manifest as drooling in
children.38 It may occur at any age with its prevalence
increasing in adults.36,39 Most commonly due to Haemo-
philus influenza type B (Hib), other causes, including group
A beta-haemolytic streptococci are on the rise, likely
related to widespread Hib vaccine use.40
“Steeple” and “wine bottle” signs of
laryngotracheobronchitis
Laryngotracheobronchitis (i.e., croup) is a viral airway
infection affecting children between the age of 6 months
and 3 years, usually due to parainfluenza or respiratory
syncytial virus.41,42 Typically self-limited, patients exhibit a
stereo- typical “barking” cough and inspiratory stridor.43
Frontal radiographs demonstrate narrowing of the lateral
convex- ities of the subglottic larynx and trachea due to
subglottic oedema, which resembles the shape of a
“steeple” or “wine
 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12 e7

Figure 10 “Thumb” sign of epiglottitis. (a) Lateral radiograph of the soft tissues of the neck in a child with fever and sore throat demonstrates
thickening and enlargement of the epiglottis (white open arrow). (b) The appearance of the oedematous epiglottis resembles a thumb and
heralds an emergent finding.

bottle”44 (Fig 11). Radiologists must be aware that false

positives can occur if expiratory films are obtained. panda46 (Fig 12). Although the “panda” sign is most
commonly seen with sarcoidosis, less common aetiologies
of symmetric accumulation of radiotracer within the
Salivary glands lacrimal and salivary glands also include lymphoma post-
radiation therapy, Sjo€ gren’s syndrome, and human
“Panda” sign of sarcoidosis immu- nodeficiency virus (HIV).46

Sarcoidosis is a chronic granulomatous disease

commonly resulting in reactive cervical adenopathy, but
also demonstrating symmetric involvement of the salivary
and lacrimal glands in approximately 80% of patients. 45
Patients with sarcoidosis may demonstrate increased
radiotracer activity symmetrically in the lacrimal and pa-
rotid glands, as well as avid physiological uptake in the
nasopharynx on gallium-67 scintigraphy, an appearance
that has been likened to the dark facial markings of a giant
Neck soft tissues
“Target” sign of neurofibroma
Neurofibromas are typically benign nerve sheath tu-
mours that arise central to the nerve of origin. 10 When
viewed in cross-section on MRI, they commonly demon-
strate concentric dark and bright T2 signal intensity
resembling a “target” (Fig 13). This “target” sign is highly

Figure 11 “Steeple” and “wine bottle” signs of laryngotracheobronchitis. (a) Anteroposterior radiograph of the neck in a child with cough and
fever demonstrates narrowing of the lateral convexities of the subglottic larynx and upper trachea (white open arrow) due to subglottic oedema
from croup. (b) This appearance resembles the silhouette of a steeple or wine bottle.
e8 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12

Figure 12 “Panda” sign of sarcoidosis. (a) Gallium-67 scintigraphy demonstrates abnormal symmetric radiotracer uptake in the parotid (white
solid arrow) and lacrimal glands (black solid arrow), as well as avid physiological activity in the nasopharynx (white arrowhead). (b) This
pattern of radiotracer uptake resembles the facial markings of the giant panda and is most typically associated with sarcoidosis, although several
other less common aetiologies can demonstrate this pattern.

Figure 13 “Target” sign of neurofibroma. (a) Axial T2-weighted image demonstrates a heterogeneously hyperintense extradural mass extending
into the left C2eC3 neuroforamen, which shows concentric rings of signal intensity (white solid arrow). (b) This cross-sectional appearance
resembles a “target” and is a characteristic, but not pathognomonic finding of neurofibromas. (c) Coronal short tau inversion recovery (STIR) in a
child with NF1 demonstrates numerous “target” signs (white open arrows) in a plexiform neurofibroma of the right face.

suggestive of neurofibromas,47,48 but can also be encoun- tered

in schwannomas with areas of intramural cyst or high Antoni
B content49 and malignant peripheral nerve sheath tumours. 47
The vast majority of neurofibromas are sporadic with only
about 10% associated with neurofibromatosis type 1 (NF1).50
The “target” sign can also be seen in the setting of plexiform
neurofibromas (Fig 13), which are encountered in
approximately 30% of NF1 patients and are pathognomonic
for NF1 if present. 51 It is critical to keep in mind that
approximately 5% of patients with NF1 will develop a ma-
lignant peripheral nerve sheath tumour at some point dur-
ing life, which necessitates vigilant surveillance.52
“Salt and pepper” sign of paraganglioma
Paragangliomas are vascular masses of chemoreceptor
cells found within the carotid space in the H&N. Para-
gangliomas of the H&N most commonly present a slow-
growing, painless, pulsatile carotid space mass, 53 typically
lacking the “pain, pallor, palpitations, and perspiration”
phenomena seen with paragangliomas elsewhere in the
body.54 Paragangliomas within the middle ear, jugular fo-
ramen, and carotid space are avidly enhancing with
pathognomonic speckled MRI signal intensity resembling
“salt and pepper”55,56 (Fig 14). The black “pepper” corre-
sponds to prominent flow voids, often seen at the
periphery of the mass and best appreciated on T2-
weighted imag- ing.56 The white “salt” corresponds to slow
flow or subacute haemorrhage seen on non-contrast T1-
weighted imaging.56 In a minority of cases, paragangliomas
are multiple and can be seen in the setting of several
syndromes, including suc- cinate dehydrogenase
deficiency, multiple endocrine neoplasia type 2, von
HippeleLindau, and NF1.57e59
“Lyre” sign of carotid body tumour
Due to characteristic splaying of the internal carotid ar-
tery (pushed posterolateral) and external carotid artery
 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12 e9

Figure 14 “Salt and pepper” sign of paraganglioma. (a) Axial non-contrast enhanced T1-weighted image demonstrates a circumscribed mass
(white arrowhead) splaying the internal and external carotid arteries and demonstrating a speckled appearance with foci of intrinsic bright T1
signal (white open arrows). (b) Axial T2-weighted imaging shows the mass (white arrowhead) to have areas of peripheral dark T2 signal (white
solid arrows). (c) This pattern has been likened to the appearance of “salt and pepper” and is pathognomonic for paraganglioma.

(pushed anteromedial), the angiographic appearance of a

striated pattern resembling the striped coat of a tiger
carotid body tumour has been likened to the shape of a lyre
(Fig 16). Progression of non-suppurative tonsillophar-
(Fig 15).60 As with other paragangliomas, carotid body tu-
yngitis to abscess or mediastinitis can occur, but is
mours demonstrate the typical “salt and pepper” appear-
extremely rare.63 When the “tiger stripe” sign is identi- fied,
ance on MRI.
it essentially excludes a concurrent intratonsillar abscess.

“Tiger stripe” sign of non-suppurative tonsillopharyngitis

“Kissing carotids” sign of medialised internal carotid
arteries
Non-suppurative tonsillopharyngitis is an acute
infection-related inflammation of the tonsils and pharynx
A medialised course of the internal carotid arteries is a
that is frequently encountered in children and young
benign, normal anatomical variant commonly encountered
adults.61 Most commonly due to respiratory viral infec-
by H&N imagers. When the carotid arteries approximate at
tion, at least one-third of cases are bacterial, most
the midline they are referred to as “kissing carotids”
commonly group A b-haemolytic streptococci.62 On (Fig 17). Although this is typically an incidental finding, it
contrast-enhanced CT imaging of the neck, patients may uncommonly manifest as a pulsatile retropharyngeal
demonstrate enlargement and hyperenhancement of the
mass and mimic a submucosal mass on fluoroscopy.64
nasopharyngeal, palatine, and base of tongue lymphoid
Although most commonly encountered in the neck, often
tissue with subjacent tonsillar oedema, which results in a

Figure 15 “Lyre” sign of carotid body tumour. (a) Lateral digital subtraction angiography image demonstrates a hypervascular mass (white solid
arrow) located at the carotid bifurcation (black solid arrow). (b) Characteristic splaying of the internal carotid artery (white open arrow) and
external carotid artery (white arrowhead) by a paraganglioma of the carotid body resembles the lyre, a harp-like instrument of classic Greek
antiquity.
e10 N.A. Koontz et al. / Clinical Radiology xxx (2016) e1ee12

Figure 16 “Tiger stripe” sign of non-suppurative tonsillopharyngitis. (a) Coronal contrast-enhanced CT image demonstrates enlargement of the
palatine tonsils, which are hyperaemic and show a striated pattern of enhancement (white open arrows). (b) This pattern of enhancement
resembles the striped coat of a tiger and when present usually excludes the diagnosis of tonsillar abscess.

Figure 17 “Kissing carotids” sign of medialised course of the internal carotid arteries. (a) Axial contrast-enhanced CT image shows a markedly
medialised course of the internal carotid arteries, which nearly contact at midline (white open arrow). (b) The close proximity of the carotids has
been described as resembling the kissing embrace of lovers (Unconditional Surrender sculpture, San Diego, California). Although typically an
incidental finding, a medialised course of the internal carotid arteries may place them at increased risk of iatrogenic injury during surgery or
instrumentation.

at the level of the oropharynx, intracranial “kissing ca-

rotids” can occur within the sphenoid sinus, sphenoid
bone, or sella.65 Due to the risk for vascular injury during
routine surgical procedures or instrumentation, this
finding warrants mention on staging CT or MRI of
pharyngeal or intracranial malignancy to prevent iatro-
genic injury.66,67
Conclusion
Radiology learners and practising radiologists alike may
benefit from familiarity with classic imaging signs of H&N
imaging. This simplified, pattern-based approach allows for
rapid recognition of complex and critical pathologies,
several of which may result in poor patient outcomes if the
diagnosis is not made correctly or in a timely manner.
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