DOI:10.2214/AJR.07.2212
AJR 2007; 189:488-497
© American Roentgen Ray Society
Masticator Space: CT and MRI of Secondary Tumor Spread
Yi Wei1,
Jiahe Xiao and
Ling Zou
1 All authors: Department of Radiology, West China Hospital, Sichuan University,
37 Guoxue Ln., Chengdu, Sichuan, 610041, China.
Received November 8, 2006;
accepted after revision March 28, 2007.
Address correspondence to Y. Wei
(weiyi_scu{at}hotmail.com).
Abstract
OBJECTIVE. In this article, we review the CT and MRI features of
secondary involvement of the masticator space in a variety of tumors. We focus
on showing various patterns of tumor spread to the masticator space.
CONCLUSION. Secondary masticator space involvement is not rare.
Familiarity with the anatomy of the masticator space and its anatomic
relationship with adjacent structures is important for imaging
interpretation.
Keywords: anatomy • buccal space • CT • head and neck imaging • masticator space • MRI • oncologic imaging
Introduction
The masticator space is a fascial space that can be invaded by
tumors from adjacent structures or from hematogenous metastases. Tumor
invasion of the masticator space usually upstages the original tumors. The
secondary tumor may also extend intracranially from the masticator space along
the neurovascular bundle. Trismus that commonly accompanies masticator space
involvement often makes physical examination difficult. CT and MRI can clearly
delineate the extent of the tumor. In this article, we review the anatomy and
imaging features of secondary tumor spread to the masticator space.
Anatomy of the Masticator Space
The masticator space is enclosed by the superficial layer of the deep
cervical fascia. This layer of fascia, also known as the investing fascia,
splits at the lower edge of the mandible. The outer layer encloses the
masseter muscle, extends over the zygomatic arch, and attaches to the
temporalis muscle and the lateral orbital wall. The inner layer covers the
medial pterygoid muscle before fusing with the interpterygoid fascia and
continues to the skull base. The split layers of the investing fascia fuse
along the ventral and dorsal borders of the ramus, thus enveloping the
masticator space completely [1,
2]. The contents of this space
are mainly the mandibular nerve and its branches, internal maxillary artery
and its branches, adipose tissue, and masticatory muscles (Fig.
1A,
1B,
1C,
1D).
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Fig. 1A —Anatomy of masticator space in healthy 34-year-old man. LP = lateral
pterygoid muscle, M = masseter muscle, MP = medial pterygoid muscle, P =
parapharyngeal space, Pa = parotid gland, T = temporalis muscle.
Contrast-enhanced axial (A) and coronal (B) CT images and
unenhanced axial (C) and contrast-enhanced coronal (D)
T1-weighted images. Internal maxillary artery (horizontal arrows,
A and B) emanates from external carotid artery (vertical
arrow, A), entering masticator space deep in relation to neck of
mandible. Mandibular nerve exits trigeminal ganglion (horizontal
arrow, D) and enters masticator space (arrowheads,
C and D) through foramen ovale (vertical arrow,
B), lying between medial and lateral pterygoid muscles. Vertical arrows
in C show pterygopalatine fossae, and oblique arrows in C and
D show zygomatic arch.
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Fig. 1B —Anatomy of masticator space in healthy 34-year-old man. LP = lateral
pterygoid muscle, M = masseter muscle, MP = medial pterygoid muscle, P =
parapharyngeal space, Pa = parotid gland, T = temporalis muscle.
Contrast-enhanced axial (A) and coronal (B) CT images and
unenhanced axial (C) and contrast-enhanced coronal (D)
T1-weighted images. Internal maxillary artery (horizontal arrows,
A and B) emanates from external carotid artery (vertical
arrow, A), entering masticator space deep in relation to neck of
mandible. Mandibular nerve exits trigeminal ganglion (horizontal
arrow, D) and enters masticator space (arrowheads,
C and D) through foramen ovale (vertical arrow,
B), lying between medial and lateral pterygoid muscles. Vertical arrows
in C show pterygopalatine fossae, and oblique arrows in C and
D show zygomatic arch.
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Fig. 1C —Anatomy of masticator space in healthy 34-year-old man. LP = lateral
pterygoid muscle, M = masseter muscle, MP = medial pterygoid muscle, P =
parapharyngeal space, Pa = parotid gland, T = temporalis muscle.
Contrast-enhanced axial (A) and coronal (B) CT images and
unenhanced axial (C) and contrast-enhanced coronal (D)
T1-weighted images. Internal maxillary artery (horizontal arrows,
A and B) emanates from external carotid artery (vertical
arrow, A), entering masticator space deep in relation to neck of
mandible. Mandibular nerve exits trigeminal ganglion (horizontal
arrow, D) and enters masticator space (arrowheads,
C and D) through foramen ovale (vertical arrow,
B), lying between medial and lateral pterygoid muscles. Vertical arrows
in C show pterygopalatine fossae, and oblique arrows in C and
D show zygomatic arch.
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Fig. 1D —Anatomy of masticator space in healthy 34-year-old man. LP = lateral
pterygoid muscle, M = masseter muscle, MP = medial pterygoid muscle, P =
parapharyngeal space, Pa = parotid gland, T = temporalis muscle.
Contrast-enhanced axial (A) and coronal (B) CT images and
unenhanced axial (C) and contrast-enhanced coronal (D)
T1-weighted images. Internal maxillary artery (horizontal arrows,
A and B) emanates from external carotid artery (vertical
arrow, A), entering masticator space deep in relation to neck of
mandible. Mandibular nerve exits trigeminal ganglion (horizontal
arrow, D) and enters masticator space (arrowheads,
C and D) through foramen ovale (vertical arrow,
B), lying between medial and lateral pterygoid muscles. Vertical arrows
in C show pterygopalatine fossae, and oblique arrows in C and
D show zygomatic arch.
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Imaging Features of Secondary Tumor Involvement of the Masticator Space
The fat content and anatomic symmetry facilitate detection of tumor spread
into the masticator space. Effacement of the fat plane, a deformity or
soft-tissue mass in the space, swelling or atrophy of the masticatory muscles,
or destruction of the mandibular ramus may be seen on CT and MRI. Tumors may
invade the masticator space along various pathways.
Pterygopalatine Fossa
The pterygopalatine fossa lies medial to the masticator space and
communicates with the latter through the pterygomaxillary fissure. The
pterygopalatine fossa also connects with the orbit through the infraorbital
fissure, with the nasal cavity through the sphenopalatine foramen, with the
oral cavity through the greater and lesser palatine foramina, and with the
middle cranial fossa through the foramen rotundum. Tumors from surrounding
structures can extend into the pterygopalatine fossa through the previously
mentioned routes and can continue to spread into the masticator space (Figs.
2A,
2B and
3A,
3B,
3C). Primary tumors of the
pterygopalatine fossa, such as juvenile angiofibroma and schwannoma, can
extend into the masticator space through the pterygomaxillary fissure (Figs.
4 and
5). Tumor involvement of the
pterygopalatine fossa manifests as effacement of the fat plane and enlargement
of the fossa on both CT and MRI.
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Fig. 2A —Squamous cell carcinoma of right soft palate in 40-year-old woman.
Contrast-enhanced CT images show mass in right soft palate (arrow,
A) extending into right pterygopalatine fossa (long arrow,
B) via greater palatine canal and thereby invading masticator space
through pterygomaxillary fissure (short arrow, B). Arrowhead
in B shows normal contralateral pterygopalatine fossa.
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Fig. 2B —Squamous cell carcinoma of right soft palate in 40-year-old woman.
Contrast-enhanced CT images show mass in right soft palate (arrow,
A) extending into right pterygopalatine fossa (long arrow,
B) via greater palatine canal and thereby invading masticator space
through pterygomaxillary fissure (short arrow, B). Arrowhead
in B shows normal contralateral pterygopalatine fossa.
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Fig. 3B —Hemangioma of left orbit in 57-year-old man. Contrast-enhanced
images show mass entering left pterygopalatine fossa (arrowhead,
C) through infraorbital fissure (arrowhead, B) and
extending into masticator space (star, C). Right infraorbital
fissure (arrow, B) and pterygopalatine fossa (arrow,
C) are normal.
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Fig. 3C —Hemangioma of left orbit in 57-year-old man. Contrast-enhanced
images show mass entering left pterygopalatine fossa (arrowhead,
C) through infraorbital fissure (arrowhead, B) and
extending into masticator space (star, C). Right infraorbital
fissure (arrow, B) and pterygopalatine fossa (arrow,
C) are normal.
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Fig. 4 —Juvenile angiofibroma of left pterygopalatine fossa in
17-year-old boy. Contrast-enhanced CT image reveals intensely enhanced mass
centered in left pterygopalatine fossa (star). Mass extends laterally
into masticator space (arrowhead) via pterygomaxillary fissure. Right
pterygopalatine fossa (arrow) is normal.
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Fig. 5 —Schwannoma of right pterygopalatine fossa in 28-year-old
woman. Contrast-enhanced CT image displays unenhanced mass in right
pterygopalatine fossa (star). Mass extends into fat planes between
masticatory muscles of right masticator space (short arrows). Left
pterygopalatine fossa (long arrow) is normal.
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Buccal Space
The buccal space is anterior to the masticator space. It has no complete
fasciae separating it from the adjacent spaces
[3,
4]. The buccal fat pad is
continuous with the fat anterior to the mandibular ramus and provides a
communication with the masticator space. The most common primary tumors in the
buccal space are minor salivary tumors, hemangiomas, lipomas, and sarcomas
[4]. Malignant primary tumors
of this space can spread posteriorly along the fat pad into the masticator
space (Fig. 6A,
6B,
6C). Cancers of the lower
gingiva in the molar region may invade the buccal space by tunnelling through
the alveolar bone and may continue to spread posteriorly into the masticator
space [5] (Fig.
7A,
7B,
7C,
7D).
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Fig. 6A —Rhabdomyosarcoma of right buccal space in 30-year-old woman.
Contrast-enhanced CT images show mass in right buccal space (horizontal
arrow, A), lateral to buccinator muscle (arrowhead,
A), extending posteriorly to anterior aspect of ramus (horizontal
arrow, B), and entering masticator space (star,
C). Left buccal space (oblique arrows, A and B)
and left masticator space (arrow, C) are normal.
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Fig. 6B —Rhabdomyosarcoma of right buccal space in 30-year-old woman.
Contrast-enhanced CT images show mass in right buccal space (horizontal
arrow, A), lateral to buccinator muscle (arrowhead,
A), extending posteriorly to anterior aspect of ramus (horizontal
arrow, B), and entering masticator space (star,
C). Left buccal space (oblique arrows, A and B)
and left masticator space (arrow, C) are normal.
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Fig. 6C —Rhabdomyosarcoma of right buccal space in 30-year-old woman.
Contrast-enhanced CT images show mass in right buccal space (horizontal
arrow, A), lateral to buccinator muscle (arrowhead,
A), extending posteriorly to anterior aspect of ramus (horizontal
arrow, B), and entering masticator space (star,
C). Left buccal space (oblique arrows, A and B)
and left masticator space (arrow, C) are normal.
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Fig. 7A —Squamous cell carcinoma of right lower gingiva in 62-year-old man.
Contrast-enhanced CT images reveal gingival mass (star, A)
that destroys alveolar bone (arrows, A and B), invades
buccal space (arrowheads, A and C), spreads posteriorly
to destroy ramus (arrow, C), and enters masticator space
(black arrows, D). Left masticator space (white
arrow, D) is normal.
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Fig. 7B —Squamous cell carcinoma of right lower gingiva in 62-year-old man.
Contrast-enhanced CT images reveal gingival mass (star, A)
that destroys alveolar bone (arrows, A and B), invades
buccal space (arrowheads, A and C), spreads posteriorly
to destroy ramus (arrow, C), and enters masticator space
(black arrows, D). Left masticator space (white
arrow, D) is normal.
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Fig. 7C —Squamous cell carcinoma of right lower gingiva in 62-year-old man.
Contrast-enhanced CT images reveal gingival mass (star, A)
that destroys alveolar bone (arrows, A and B), invades
buccal space (arrowheads, A and C), spreads posteriorly
to destroy ramus (arrow, C), and enters masticator space
(black arrows, D). Left masticator space (white
arrow, D) is normal.
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Fig. 7D —Squamous cell carcinoma of right lower gingiva in 62-year-old man.
Contrast-enhanced CT images reveal gingival mass (star, A)
that destroys alveolar bone (arrows, A and B), invades
buccal space (arrowheads, A and C), spreads posteriorly
to destroy ramus (arrow, C), and enters masticator space
(black arrows, D). Left masticator space (white
arrow, D) is normal.
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Pterygomandibular Raphe
The pterygomandibular raphe is a band of connective tissues situated
beneath the mucosal surface of the retromolar triangle and the insertion point
for the buccinator, orbicularis oris, and superior constrictor muscles
[6]. It attaches superiorly to
the hook of the hamulus of the medial pterygoid plate and inferiorly to the
posterior aspect of the mylohyoid line of the mandible. Tumors can spread
along this plane into the pterygomandibular space of the masticator space
[7]. Primary malignancy of the
retromolar triangle and gingival cancer spreading into the retromolar triangle
can invade the masticator space through the pterygomandibular raphe without
destruction of the ramus [5].
Buccal cancers can extend submucosally along the buccinator muscle to the
pterygomandibular raphe [6] and
masticator space (Fig. 8).
Oropharyngeal and nasopharyngeal malignancies may spread to the
pterygomandibular raphe and masticator space via the superior constrictor
muscles (Fig. 9).
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Fig. 8 —Squamous cell carcinoma of right buccal mucosa in 58-year-old
man. Mass (star) infiltrates submucosal fat plane, buccinator muscle,
and expected location of pterygomandibular raphe and extends into
pterygomandibular space (arrowhead), part of masticator space. Left
buccinator (long horizontal arrow) and submucosal fat plane
(short horizontal arrow) are normal. Left expected location of
pterygomandibular raphe (oblique arrow) is normal.
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Fig. 9 —Squamous cell carcinoma of right lateral oropharyngeal wall
in 71-year-old man. Mass (star) in oropharynx spreads to expected
location of pterygomandibular raphe and invades masticator space
(arrows). Left expected location of pterygomandibular raphe
(arrowhead) is normal.
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Natural Anatomic Holes and Foramina
There are several natural anatomic holes and foramina through which the
masticator space communicates with adjacent structures. The foramen ovale,
through which the mandibular nerve exits the cranium, is just at the roof of
the masticator space. Schwannoma of the trigeminal ganglion and meningioma can
extend into the masticator space through this foramen
(Fig. 10). There are also
holes in the parotid fascia where the external carotid artery and nerves
perforate the fascia and enter the masticator space. Parotid tumors may spread
along the neurovascular bundle into the masticator space via these holes
(Fig. 11). Nasopharyngeal
carcinoma can invade the masticator space through the sinus of Morgagni, a
natural fascial defect of the pharyngobasilar fascia situated in the superior
portion of the lateral wall of the nasopharynx.
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Fig. 10 —Schwannoma of trigeminal ganglion in 22-year-old man.
Contrast-enhanced coronal T1-weighted image shows heterogeneously enhanced
mass (star) that extends inferiorly via foramen ovale
(arrow) and lies between pterygoid muscles of masticator space
(arrowhead).
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Fig. 11 —Adenoid cystic carcinoma of right parotid gland in
51-year-old man. Small portion of parotid mass (star) extends into
masticator space (horizontal arrow) along internal maxillary artery
(thin oblique arrow). Left masticator space (thick oblique
arrow) is normal.
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Perineural Spread
Perineural spread refers to a metastatic pattern in which tumors spread
along the neural sheath via the endoneurium, perineurium, or perineural
lymphatics [8,
9]. Perineural spread is not
rare in head and neck malignancies. The nerves in the masticator space are
mainly the mandibular nerve and its branches. Although tumors in any anatomic
location supplied by the mandibular nerve can have retrograde perineural
spread to the masticator space (Fig.
12A,
12B,
12C,
12D), the auriculotemporal and
inferior alveolar nerves are most commonly associated with perineural spread
[8]. The auriculotemporal nerve
arises from two roots that emanate from the mandibular nerve. The roots,
surrounding the middle meningeal artery, run posteriorly deep in relation to
the lateral pterygoid muscle and pass between the neck of the mandible and the
sphenomandibular ligament, where they merge and branch to join the facial
nerve [1,
10]. Parotid or lateral facial
tumors can spread along the auriculotemporal nerve to the masticator space
(Fig. 13A,
13B,
13C,
13D).
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Fig. 12A —Recurrent adenoid cystic carcinoma of right submandibular gland with
perineural spread along lingual nerve in 65-year-old man. Contrast-enhanced
T1-weighted images reveal enhanced infiltrating mass (arrowheads) in
right sublingual space. Left mylohyoid muscle (long arrows),
hyoglossus muscle (short arrows), and sublingual space are
normal.
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Fig. 12B —Recurrent adenoid cystic carcinoma of right submandibular gland with
perineural spread along lingual nerve in 65-year-old man. Contrast-enhanced
T1-weighted images reveal enhanced infiltrating mass (arrowheads) in
right sublingual space. Left mylohyoid muscle (long arrows),
hyoglossus muscle (short arrows), and sublingual space are
normal.
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Fig. 12C —Recurrent adenoid cystic carcinoma of right submandibular gland with
perineural spread along lingual nerve in 65-year-old man. Images rostral to
B show enhanced nodules at expected location of lingual nerve
(arrowheads). Note atrophied right masticatory muscles
(arrows, D).
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Fig. 12D —Recurrent adenoid cystic carcinoma of right submandibular gland with
perineural spread along lingual nerve in 65-year-old man. Images rostral to
B show enhanced nodules at expected location of lingual nerve
(arrowheads). Note atrophied right masticatory muscles
(arrows, D).
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Fig. 13A —Adenoid cystic carcinoma of left parotid gland with perineural
spread along auriculotemporal nerve in 36-year-old man. Contrast-enhanced CT
images show mass in left parotid gland (arrows, A) that
infiltrates along auriculotemporal nerve (arrowhead, B)
between medial pterygoid muscle (black arrow, B) and lateral
pterygoid muscle (white arrow, B), spreads to mandibular
nerve, and extends superiorly to trigeminal ganglion and cavernous sinus
(arrow, D) via enlarged foramen ovale (arrowhead,
C). Note atrophied left masticatory muscles and normal right foramen
ovale (arrow, C).
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Fig. 13B —Adenoid cystic carcinoma of left parotid gland with perineural
spread along auriculotemporal nerve in 36-year-old man. Contrast-enhanced CT
images show mass in left parotid gland (arrows, A) that
infiltrates along auriculotemporal nerve (arrowhead, B)
between medial pterygoid muscle (black arrow, B) and lateral
pterygoid muscle (white arrow, B), spreads to mandibular
nerve, and extends superiorly to trigeminal ganglion and cavernous sinus
(arrow, D) via enlarged foramen ovale (arrowhead,
C). Note atrophied left masticatory muscles and normal right foramen
ovale (arrow, C).
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Fig. 13C —Adenoid cystic carcinoma of left parotid gland with perineural
spread along auriculotemporal nerve in 36-year-old man. Contrast-enhanced CT
images show mass in left parotid gland (arrows, A) that
infiltrates along auriculotemporal nerve (arrowhead, B)
between medial pterygoid muscle (black arrow, B) and lateral
pterygoid muscle (white arrow, B), spreads to mandibular
nerve, and extends superiorly to trigeminal ganglion and cavernous sinus
(arrow, D) via enlarged foramen ovale (arrowhead,
C). Note atrophied left masticatory muscles and normal right foramen
ovale (arrow, C).
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Fig. 13D —Adenoid cystic carcinoma of left parotid gland with perineural
spread along auriculotemporal nerve in 36-year-old man. Contrast-enhanced CT
images show mass in left parotid gland (arrows, A) that
infiltrates along auriculotemporal nerve (arrowhead, B)
between medial pterygoid muscle (black arrow, B) and lateral
pterygoid muscle (white arrow, B), spreads to mandibular
nerve, and extends superiorly to trigeminal ganglion and cavernous sinus
(arrow, D) via enlarged foramen ovale (arrowhead,
C). Note atrophied left masticatory muscles and normal right foramen
ovale (arrow, C).
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MRI is superior to CT in displaying perineural spread as smooth thickening
and enhancement of the involved nerve, concentric expansion of the implicated
foramina, involvement of the cavernous sinus, and denervation atrophy of the
masticatory muscles (Figs.
12A,
12B,
12C,
12D and
13A,
13B,
13C,
13D).
Direct Tumor Invasion
Some tumors do not take the previously mentioned pathways to the masticator
space; instead, they invade this space through destroying the bones between
the masticator space and the structures having lesions. Primary malignancy or
upper gingival cancer involving the maxillary sinus can destroy the posterior
wall of the sinus and invade the masticator space
(Fig. 14). Nasopharyngeal
carcinoma may destroy the pterygoid plates to invade the masticator space.
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Fig. 14 —Squamous cell carcinoma of right maxillary sinus in
48-year-old man. Contrast-enhanced CT image reveals mass (star) in
right maxillary sinus that has destroyed posterior wall of sinus and spread
into masticator space (arrow). Left maxillary sinus and masticator
space (arrowhead) are normal.
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Hematogenous Spread
Hematogenous metastasis and extranodal lymphoma may destroy the mandibular
ramus or skull base, may involve the muscles of mastication in the masticator
space, or both [11] (Fig.
15A,
15B).
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Fig. 15A —Extranodal non-Hodgkin's lymphoma in 15-year-old boy.
Contrast-enhanced axial CT image shows infiltrating mass (star) in
left masticator space involves pterygoid muscles and extends into
pterygopalatine fossa (arrow).
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Fig. 15B —Extranodal non-Hodgkin's lymphoma in 15-year-old boy. Reformatted
contrast-enhanced coronal CT image reveals mass (arrowhead) that
eroded skull base (arrow), and roof of masticator space.
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Abstract
Introduction
