Carcinoma or suspected malignancy in the larynx region
Vocal cord nodules or polyps or other cord disorders
Trauma to the laryngeal region
Reconstruction planning of the larynx/vocal cords
Post-radiation therapy changes to the larynx area and vocal cords
Equipment and coils:
Anterior neck coil is preferred
Some setups have coil options for TMJs or other regions, but for the neck use the anterior neck coil
Patient positioning and immobilization:
Patient is supine
Place a wedge under the feet and knees to flex the legs (comfortable positioning)
Longitudinal light placed midline, then a horizontal line through the thyroid cartilage (just below the Adam's apple) or just below the hyoid bone
Centering: head in neutral, IPL (pupillary line) parallel to the imaging plane; prevent head tilt
Landmarks and centering principles:
Centering point around the mid-neck region, roughly around vertebral levels C3–C5
The exam targets tiny structures in this area; expect to use thin slice gaps for high detail
Planes, localization, and coverage:
Field of view planned to cover from the mouth/hard palate down to the sternoclavicular (SC) joints, i.e., the anterior neck region
Coverage can extend from the hard palate to the SC joints; the field can be tailored to shrink unnecessarily into the brain if not required
Localizers typically axial or coronal; sagittal localizer used to set up sagittal images
Slice orientation and relationships:
Axial slices: set to be parallel to the larynx for tumor evaluation; acquired from a coronal or axial localizer, then sagittal reconstructions
Sagittal fast spin echo sequence (for testing): typically used for sagittal coverage; mention of a T1/T2 variant may appear in slides but may not be tested
Coronal fast spin echo T1: similar to C-spine planning, box moved downward to include anterior neck; ensure field includes all relevant anatomy from hard palate to SC joints
The coronal prescription is often like a C-spine or head study, with adjustments to include the anterior neck anatomy
Axial and coronal planning details:
Axial slices are very thin; anatomy is small; best to set up with axial or coronal localizers first, then acquire the axial stack parallel to the larynx
Coronal slices should be obtained from posterior to anterior, moving inferiorly; consider keeping field of view forward from the spine
Try to include the hard palate and the SC joint in the coverage; may require reducing the superior field of view to avoid unnecessary brain imaging
Specific sequences commonly used:
Axial fast spin echo sequences (T1, T2): thin slices; parallel to the larynx
Coronal fast spin echo sequences (T1): broad overview of thyroid/cartilage and laryngeal structures
Sagittal fast spin echo sequence (noted as possible T1/T2 in slides; may not be on the test)
Additional notes:
The coronal and sagittal stack planning should resemble the C-spine workflow; images acquired as axials, coronal, and sometimes sagittals depending on protocol
The goal is to obtain crisp detail of tiny laryngeal structures with thin slices and minimal aliasing
Operator might adjust slice thickness, gaps, and orientation to maximize coverage of the thyroid cartilage, hyoid bone, Adam's apple, and surrounding soft tissue
Functional Imaging and Specialized Neck Sequences
Phonation (vocal cord function) imaging:
During phonation (speaking/motion of vocal cords), use a fast and coherent spoiled gradient echo sequence to assess function
Functional imaging can be used to evaluate how the cords move, and may be part of exam discussion on vocal function
Fat suppression and post-processing:
In some protocols, fat-suppressed post-contrast sequences are employed to improve lesion conspicuity in the neck
Thyroid and Parathyroid Imaging: Indications and Protocols
Indications:
Goiter assessment, thyroid nodules, and potential thyroid cancer detection
Post-radiation therapy changes in the thyroid region
Evaluation of possible parathyroid abnormalities or nodules
Practical anatomy notes:
The thyroid gland sits in the midline neck region anteriorly; surrounding structures include the thyroid cartilage and hyoid bone
The Adam's apple (thyroid cartilage) is a key landmark for orientation
Equipment and setup:
Use the same anterior neck coil as for the larynx imaging
Immobilization foam pads and supine positioning remain standard
Centering and orientation:
Horizontal light line placed just below the thyroid cartilage; approximate centering around C3–C5 levels
Coverage from the mouth/hard palate to SC joints; may extend a little above and below to include the thyroid and surrounding tissues
Protocol specifics:
Typically a combination of axial and coronal planes; sagittal may be used in some centers
Very thin slices; multiple nexuses to improve SNR and resolution
Axial slices should be parallel to the larynx in this region as well
Coronal prescription similar to thyroid imaging in neck protocols; start around the inferior thyroid region and move superiorly
Sequences and contrasts:
Axial fast spin echo T1 and T2; coronal fast spin echo T1; sagittal variants may appear
STIR sequences are useful for thyroid tumor evaluation
DWI (diffusion-weighted imaging) helps differentiate benign vs malignant processes, particularly for assessing nodal involvement
Fat-saturated post-contrast T1 sequences are commonly used to assess enhancement patterns
Post-contrast imaging can be valuable for identifying suspicious nodules or inflammatory/infectious processes
Diffusion-weighted imaging considerations:
DWI is helpful for distinguishing benign from malignant lesions and evaluating lymph nodes
SNR is often poorer in neck DWI due to motion, air/tat tissue interfaces, and small structures
Use high-SNR configurations: prefer a high-quality anterior neck coil and potentially multiple receiver channels (multiple nexuses) to improve SNR
Technical tips for neck DWI:
Expect longer scan times and potential motion; use saturation bands above and below the neck to mitigate motion and vascular pulsation artifacts
Consider a smaller FOV and careful coil selection to maximize SNR and reduce artifacts
Other practical considerations:
The anterior neck anatomy is challenging due to close proximity to air-tissue interfaces, carotid/jugular vessels, swallowing motion, and thyroid tissue signal characteristics
For goiter or thyroid cancer evaluation, use appropriate coil, thin slices, and fat suppression to enhance lesion conspicuity
Real-world relevance and anecdotes:
Public awareness anecdotes (e.g., a high-profile thyroid cancer discovery) illustrate why thyroid imaging is important for early detection and treatment planning
TMJ Imaging: Technique, Setup, and Dynamic Assessments
Indications:
Temporomandibular joint (TMJ) disorders, including meniscal derangements or internal derangements
Evaluation of jaw movement, click/catch, and assessing TMJ anatomy
Equipment:
Often two small circular coils for bilateral TMJ imaging; typical coil size is about 3'' diameter; you may use two of these if available
If dedicated TMJ coils are not available, a head coil may be used; imaging may be performed one joint at a time
Patient positioning:
Supine position with the patient relaxed
Place a mouth-opening device to maintain controlled mouth opening during imaging; common devices include simple clear plastic spacers or improvised devices like a syringe if needed
Mouth positions and planes:
Acquire images with the mouth closed first (baseline)
Then acquire images with the mouth opened to assess articulation and possible impingement or derangement
Open-mouth and closed-mouth acquisitions often include sagittal obliques and coronal planes to visualize the condyle relative to the fossa
Field-of-view and orientation:
Use a small field of view oriented to the TMJ region to maximize spatial resolution while reducing motion artifacts
Oblique sagittal planes along the jaw/condyle axis help capture joint dynamics; coronal planes help view the joint laterally
Dynamic or motion imaging:
Dynamic MRI of the TMJ (open/close mouth) can be performed to evaluate movement patterns and detect functional derangements
Some protocols use functional imaging where the patient opens and closes the mouth during acquisition
Imaging sequences:
Thin axial slices to visualize the joint and surrounding soft tissue
Coronal and sagittal plane acquisitions for comprehensive TMJ assessment
Orthogonal coronal/axial planes may be used to better align with the condylar neck and the articular eminence
Artifacts and mitigation:
Expect swallowing, jaw movement, and vascular pulsation to create artifacts
Saturation bands and a small FOV help reduce motion and vascular artifacts
Instruct patient to minimize swallowing during data acquisition; allow swallowing during non-imaging periods
Additional considerations:
If contrast is used (arthrography), gadolinium can be injected into the TMJ under T1 post-contrast sequences; this is a more invasive technique and is not routinely performed in all centers
Arthrography provides enhanced delineation of the joint capsule and intra-articular structures but can be uncomfortable due to joint injection
Practical notes:
Demonstrates the value of dynamic imaging for functional assessment of the TMJ
If dedicated TMJ coils are unavailable, a head coil remains useful with careful protocol adjustments
Acquisition Principles Across Neck Imaging: High-Quality Imaging Practices
Common high-yield principles:
Thin slices and high-resolution acquisition to visualize small structures in the neck
Use of multiple receiver channels (NEX and coil configurations) to boost SNR and detail
Rectangular or asymmetrical field-of-view (FOV) to reduce scan time while preserving needed detail
Pre- and post-contrast imaging when appropriate, including fat-saturated T1 sequences for lesion conspicuity
Artifact reduction strategies:
Saturation bands placed above and below the region of interest to mitigate venous pulsation and swallowing motion
Gradient moment nulling (to reduce certain T2* and motion-related artifacts)
In neck imaging, keep saturation bands as close to the FOV as possible without clipping anatomy
For DWI in neck imaging, ensure robust coil performance and patient immobilization to counteract low SNR
Motion management and patient instructions:
Advise patients not to swallow during image acquisition whenever possible; swallowing can cause motion artifacts
Use padding and supports to minimize breathing and posture movement; consider breathing guidance if necessary
Field-of-view and localization considerations:
The neck field of view should be carefully chosen to avoid unnecessary inclusion of brain structures while including the hard palate and SC joints when needed
If the field is extended too far superiorly or inferiorly, it can increase scan time and motion risk
Practical Imaging Scenarios and Tips
Field optimization and localizers:
Start with axial or coronal localizers, then plan sagittal sets from those; adjust to parallel the C-spine orientation
For larynx and neck exams, maintain a consistent IPL alignment and avoid head tilt to ensure reproducible slices
Sequence selection summary:
Larynx: axial fast spin echo (T1/T2), coronal fast spin echo (T1), sagittal fast spin echo (T1/T2 variants may appear but test reliability varies)
Phonation: fast spoiled gradient echo sequences to examine vocal cord motion
Thyroid/parathyroid: axial and coronal fast spin echo T1/T2, STIR, DWI, and post-contrast T1 with fat suppression as needed
TMJ: thin-slice axial, plus sagittal oblique and coronal acquisitions; dynamic imaging with mouth opening
Contrast and post-processing:
Gadolinium-based contrast may be used for post-contrast T1 imaging; fat saturation helps highlight enhancement
Consider arthrography if joint capsule delineation is needed (arthrogram with gadolinium)
Specific clinical pearls:
The anterior neck coil yields higher SNR for the neck structures; use a dedicated coil whenever possible
When imaging the TMJ, dynamic mouth movement can reveal functional abnormalities not seen on static images
The neck region presents numerous small structures; use consistent, thin slices and high-resolution protocols for reliable evaluation
Ethical, Practical, and Real-World Considerations
Clinical relevance:
Neck MRI is essential for evaluating malignancy risk, nodules, and postoperative changes in the larynx and thyroid region
Accurate imaging of the TMJ assists in diagnosing degenerative or derangement conditions and planning potential interventions
Patient safety and comfort:
Provide clear instructions about swallowing and mouth opening devices to minimize discomfort and motion
Be mindful of potential adverse reactions to contrast and ensure appropriate screening prior to gadolinium administration
Real-world anecdotes:
Public awareness stories (e.g., celebrities with thyroid cancer) underscore the importance of early detection and imaging follow-up when indicated
Quick Reference: Key Anatomical Landmarks and Planes in Neck MRI
Landmarks:
Adam's apple (thyroid cartilage)
Hyoid bone
Thyroid gland
Hard palate (mouth opening landmarks for coverage)
SC joints
Vertebral levels often used as rough anchors:
C3, C4, C_5
Planes and orientations:
Axial slices: parallel to the larynx
Coronal slices: anterior-posterior orientation, often similar to C-spine coronal planes
Sagittal slices: medial-lateral orientation, sometimes used for sagittal fast spin echo
Field of view concepts:
Narrow FOV for TMJ and neck to improve resolution and reduce motion artifacts
Broad FOV for thyroid and entire neck to capture anterior and posterior structures
Summary of Core Takeaways
Neck MRI requires precise patient positioning, appropriate coil selection (prefer anterior neck coil), and thin-slice imaging to visualize tiny laryngeal and thyroid structures
A combination of axial, coronal, and sagittal planes is used, with attention to pro-grade alignment parallel to the C-spine and larynx
Specific sequences support different clinical goals: structural assessment (T1/T2 FSE), functional evaluation (phonation with gradient echo), and tissue characterization (STIR, DWI, fat-sat post-contrast)
For TMJ imaging, dynamic (open/close) imaging and dedicated coil setups (two small circular coils) enhance evaluation of the condyle and joint space; arthrography is possible but invasive
Artifact mitigation is critical in neck imaging due to swallowing, carotid/jugular vessels, and motion; saturation bands and gradient moment nulling are common strategies
Practical considerations, including patient instructions, localizer planning, and maximizing SNR with multiple receiver channels, directly affect image quality and diagnostic yield