European Training Curriculum in Head and Neck Radiology

Introduction

Head and neck radiology is a subspecialty of radiology. Head and neck radiology comprises diagnostic imaging and procedures performed by means of all cross-sectional techniques and conventional radiography of conditions involving the petrous bone, the skull base and cranial nerves, the orbit, the nasopharynx and sinuses, the oral cavity, the oro- and hypopharynx, the larynx, the neck, the salivary glands, the facial skeleton including the teeth, the mandible and temporomandibular joints, the deep spaces of the face, the thoracic inlet, the brachial plexus and the thyroid gland (see Appendix 1).

Advances in CT, MRI, PET CT, PET MRI, US, FNAC and biopsy techniques, as well as multimodality image fusion have expanded their range of applications in the head and neck area, which constitutes with its intricate anatomy and wide spectrum of diseases a challenge for many radiologists. The need to sufficiently qualify young radiologists to make accurate diagnosis in the head and neck area have led the European Society of Head and Neck Radiology (ESHNR) to establish a head and neck radiology subspecialisation curriculum. This subspecialisation curriculum was first defined in 1996 and was published in 1997 in the European training charter for clinical radiology by the European Association in Radiology (EAR).

The purpose of the current document is to describe the contents of this subspecialisation curriculum in Head and Neck Radiology and the regulations regarding the acquirement of the European Board of Head and Neck Radiology (EBiHNR) Diploma.

Training in the subspecialty of head and neck radiology is based on a curriculum containing the following items: knowledge, skills, and competences & attitudes, as listed below.

Knowledge

To have an in-depth knowledge of the normal anatomy of the head and neck, including the skull base, temporal bone, paranasal sinuses, the oral cavity, pharynx and larynx, the middle and inner ear, salivary glands, thyroid and parathyroid glands, thoracic inlet, orbit, teeth, mandible and temporomandibular joint, lymph nodes, arterial and venous system, and the neck including deep spaces and compartments (Appendix 1) as demonstrated by CT, cone beam CT (CBCT), US, MRI, angiography, videofluoroscopy, conventional radiographs, PET CT and PET MRI
To have a good knowledge of normal variants of the head and neck, including paranasal sinuses, oral cavity, pharynx and larynx, temporal bone, skull base, orbit, teeth, temporomandibular joint, thyroid and parathyroid, salivary glands, neck and thoracic inlet
To understand clinical practice relevant symptoms and signs to pathologic conditions of the head and neck and how to investigate these according to the latest recommendations and state of the art protocols.
To understand the mean exposure doses of CT, cone bean CT (CBCT), conventional radiography, X ray angiography, X ray guided interventional procedures, radionuclide imaging and PET CT.
To have an in-depth knowledge of common and rare diseases of the eye and orbit, temporal bone and skull base, paranasal sinuses, thyroid, parathyroid and salivary glands, teeth, temporomandibular joints and mandible, pharynx and larynx, lymph nodes, vessels and soft tissues in the head and neck, thoracic inlet including the brachial plexus and deep spaces.
To have an in-depth knowledge role of US- and/or CT-guided cytology or biopsy of salivary glands, lymph nodes, thyroid gland and other head and neck masses.
To have an in-depth knowledge of the role, advantages and disadvantages of CT, ultrasound, CBCT, videofluoroscopy and MRI applications in the head and neck
To have an in-depth knowledge of the anatomy of the arterial and venous system and its relevance to interventional radiology
To describe the principles of CT, CBCT, MRI with DWI, US, PET CT, PET MRI and image processing pertinent to traumatic, inflammatory, infectious, neoplastic and congenital conditions of the head and neck
To understand the TNM classification of head and neck tumors and imaging related issues
To fully master the terminology for describing the site of lymph nodes in the head and neck region

Specific anatomic regions and related pathology

a. Temporal bone

To list, describe and differentiate common and uncommon imaging features of congenital disorders leading to deafness (e.g. cochlear aplasia/hypoplasia, Mondini malformation, large endolymphatic sac anomaly (LESA) / large vestibular aqueduct syndrome (LVAS)
To describe the imaging features and clinical features of disorders leading to secondary deafness including otosclerosis, Menière’s disease, temporal bone inflammatory disease, and tumors of the cerebellopontine angle
To confidently delineate the course of cranial nerves VI – XI in their different components
To describe the imaging and clinical features of tumors of the temporal bone and cerebello-pontine angle and to distinguish these from each other
To describe the imaging and clinical features of traumatic lesions and fractures of the temporal bone
To describe the imaging and clinical features of cholesteatoma and other inflammatory lesions
To be familiar with the different types of surgical procedures related to the middle ear and mastoid
To differentiate different pathologies of the external auditory canal, including atresia and tumorous lesions
To differentiate different pathologies of the middle ear
To be familiar with the different types of cochlea implants and their respective MRI compatibility / non-compatibility (including specific precautions)
To know the various causes of vascular tinnitus and to describe their respective imaging features

b. Facial skeleton, skull base and cranial nerves

To list the different neoplasms of the clivus and to describe their respective imaging appearance, including meningioma, macroadenoma, chordoma, chondrosarcoma and others
To describe the imaging and clinical features of lesions of the jugular foramen, including glomus tumour / paraganglioma, jugular bulb pseudolesions, jugular bulb diverticulum, dehiscent jugular bulb, jugular foramen schwannoma, jugular foramen meningioma and others
To describe the imaging features and clinical features of diffuse diseases of the skull base, including fibrous dysplasia, plasmocytoma, Langerhans cell histiocytosis, chondosarcoma and metastases
To describe the normal anatomy and function of the cranial nerves I – V and to list common and less common pathologies
To list and categorize traumatic lesions of the facial skeleton and skull base and to be familiar with complications and therapeutic consequences
To describe the typical imaging features of neoplasms of the cavernous sinus, mandible and maxilla
To understand the imaging features of jaw lesions including cysts and cyst-like lesions
To understand the imaging features of infectious and inflammatory lesions of the mandible, maxilla and skull base, including osteomyelitis, osteoradionecrosis, bisphosphonate osteonecrosis
To be familiar with post-treatment changes

c. Orbit and visual pathways

To describe the imaging and clinical features of congenital lesions of the orbit, including coloboma
To describe the imaging and clinical features of typical tumours of the orbit in children including dermoid and epidermoid cysts, cavernous haemangioma, lymphangioma, rhabdomyosarcoma and retinoblastoma
To describe the orbital manifestations of neurofibromatosis type I and other congenital diseases
To describe the imaging and clinical features of infectious and inflammatory disorders of the orbits including optic neuritis, abscesses, sarcoidosis and idiopathic inflammatory disorders
To describe the imaging and clinical features of benign tumours of the orbits in adults including meningioma, optic/chiasmal glioma, orbital haemangioma, and benign mixed tumour of the lacrimal gland
To describe the imaging and clinical features of malignant tumors of the orbits in adults such as ocular melanoma, orbital lymphoma, higher grade optic glioma, adenoid cystic carcinoma of the lacrimal glands

d. Nose, nasopharynx and paranasal sinuses

To describe the imaging and clinical features of congenital lesions of the paranasal sinuses including choanal atresia and frontoethmoidal encephalocele
To differentiate normal variants of the nose and paranasal sinuses from pathology
To describe the imaging and clinical features of infectious and inflammatory disorders of the nose and paranasal sinuses including acute and chronic rhinosinusitis, fungal sinusitis, sinonasal polyposis, sinonasal mucocele and sinonasal Wegener granulomatosis
To be knowledgeable of typical complications of infectious and inflammatory disorders of the nose and paranasal sinuses
To list and describe the typical surgical approaches to the nose and paranasal sinuses including functional endoscopic sinus surgery (FESS)
To describe the imaging and clinical features of benign and malignant neoplasms of the nose and paranasal sinuses including inverted papilloma, juvenile angiofibroma, sinonasal hemangioma, sinonasal osteoma, sinonasal fibrous dysplasia, sinonasal squamous cell carcinoma, sinonasal adenocarcinoma, sinonasal melanoma, esthesioneuroblastoma, sinonasal lymphoma and others
To describe the typical imaging features of the nose and paranasal sinuses after surgery
To describe the imaging features and clinical features of the nasopharyngeal pathologies including Thornwaldt cyst, inflammatory and infectious lesions and neoplasms

e. Masticator space, parotid space and carotid space

To describe the anatomical delineations of the masticator space, parotid space and carotid space
To describe pseudolesions of the masticator space, including denervation atrophy, benign muscle hypertrophy and asymmetries of the pterygoid venous plexus
To describe the typical and rare imaging features of abscess formations of the masticator space
To describe the imaging features and clinical features of benign and malignant neoplasms of the masticator space including peripheral nerve sheath tumors of the trigeminal nerve
To describe the imaging features and clinical features of infectious and inflammatory lesions of the parotid space including parotitis, Sjogren syndrome and benign lymphoepithelial lesions in patients with HIV
To describe the imaging features and clinical features of benign and malignant neoplasms of the parotid space including Warthin tumor, benign mixed tumor, adenoid cystic carcinoma, mucoepidermoid carcinoma, lymphoma, lymph node metastases and malignant tumors of the skin
To describe the imaging features and clinical features of vascular lesions of the carotid space including ectatic carotid arteries, carotid artery pseudoaneurysm, carotid artery dissection, and jugular venous thrombosis
To describe the imaging features and clinical features of neoplasms of the carotid space including carotid body paraganglioma, glomus vagale paraganglioma, schwannoma, and neurofibroma

f. Lymph nodes of the head and neck region

To have an in-depth understanding of the nomenclature of the lymph nodes and nodal regions
To describe the imaging features and clinical features of infectious and inflammatory disorders of the lymph nodes including reactive lymph node enlargement, suppurative lymph nodes, Kimura disease, Castleman disease and others
To describe the imaging features and clinical features of neoplastic disorders of the lymph nodes, including lymphoma (Hodgkin and Non-Hodgkin) and nodal metastases
To have an in-depth understanding of new imaging modalities and techniques including diffusion weighted imaging, perfusion, PET CT and elastography

g. Oral cavity, oropharynx and retropharyngeal space

To describe the imaging features and clinical features of congenital lesions of the oral cavity and oropharynx, including dermoid and epidermoid cysts, accessory salivary tissue, lymphangioma and lingual thyroid gland
To describe the imaging features and clinical features of inflammatory and infectious lesions of the oral cavity and oropharynx, including abscesses, retention cysts, sialoceles, sialadenitis and ranula
To describe the imaging features and clinical features of benign and malignant neoplasms of the oral cavity and oropharynx, including benign mixed tumors, squamous cell carcinoma, malignant tumors of the minor salivary glands
To describe the typical imaging features and clinical presentation of retropharyngeal abscesses and to know their patterns of spread as well as possible complications

h. Hypopharynx, larynx and cervical esophagus

To describe the imaging features and clinical features of neoplasms of the hypopharynx and larynx, including squamous cell carcinoma of the hypopharynx, of the supraglottic, glottic and subglottic regions, chondrosarcoma and other malignant tumors of the larynx
To describe the typical imaging features of the hypopharynx and larynx after surgery and after radiation
To describe the imaging features of vocal cord paralysis
To describe the potential effects and the respective imaging features of laryngeal trauma
To list the imaging features, causes and clinical consequences of tracheal stenoses
To describe the imaging features of laryngoceles and pharyngoceles, webs and strictures
To describe functional abnormalities of the larynx and hypopharynx during impaired swallowing including primary and secondary aspiration and dysfunction of the crico-pharyngeal muscle
To describe the imaging features and clinical features of cervical esophageal carcinoma
To describe the imaging features and clinical features of a Zenker diverticulum and the typical approaches to therapy
To be familiar with PET-CT findings in head and neck tumors involving the pharynx, larynx and oral cavity, common pitfalls and to understand the potential role of new tracers and their application in head and neck oncology

i. Thyroid and parathyroid glands

To describe the imaging and clinical features of thyroiditis
To describe the imaging and clinical features of multinodular goiter
To describe the imaging and clinical features of benign and malignant neoplasms of the thyroid and parathyroid glands, including thyroid and parathyroid adenomas, different types of thyroid carcinoma, and thyroid lymphoma
To be familiar with the most important findings of Tc-99m-scintigraphy and PET/CT in various diseases of the thyroid gland

j. Congenital and trans-spatial lesions

To have a good understanding of the embryology of the head and neck region
To describe the imaging features and clinical features of branchial cleft cysts
To describe the imaging features and clinical features of thyroglossal duct cysts
To describe the imaging features and clinical features of thymus cysts
To describe the imaging features and clinical features of vascular lesions including malformations of the head and neck region
To describe imaging manifestations of neurocutaneous syndromes, including neurofibromatosis type I and II in the head and neck region
To describe the imaging features and clinical features of fibromatosis colli
To have a good knowledge of congenital malformations of the skull base and face and in particular of the inner ear and middle ear
To plan and to protocol contrast enhanced CT, CBCT, MRI and PET CT for the evaluation of pathologic conditions of the head and neck
To understand and to be able to adapt the parameters of MRI sequences in order to avoid poor quality images and to obtain the information necessary for the diagnosis
To be able to perform the 2D and 3D reconstructions necessary for the interpretation / illustration of findings as well as more advanced postprocessing techniques including multimodality data fusion and multiple layers reconstructions.
To be able to perform independently videofluoroscopy of deglutition, US, US guided FNAC, CT guided FNAC or US / CT guided biopsy, dacryocystography or fistulography.
To justify when and why a particular examination needs to be performed in the head and neck
To choose the best suited method for the assessment of pathologies of the head and neck
To communicate with the patient in order to obtain informed consent
To choose optimal imaging parameters for a given examination
To apply techniques to reduce exposure doses for CT, CBCT, videofluoroscopy of deglutition, angiography and X ray guided procedures
To supervise and teach technical staff to ensure that good quality examinations are obtained
To report the findings with respect to common and uncommon diseases
To appreciate own limitations and to identify when it is appropriate to obtain assistance
To identify urgent and/or unexpected findings in the head and neck and to communicate these timely and properly
To communicate with patients and their relatives in order to explain pathologic findings
To perform multi-disciplinary conferences and tumor boards
To be able to critically review the current literature and its applications in every day head and neck radiology
To continuously improve and adapt imaging protocols according to new technical developments
To be able to teach younger residents the basics of standard imaging interpretation in the head and neck
To be able to participate and contribute effectively to research projects initiated by experienced colleagues and/or to initiate research or educational projects involving the head and neck area
To be able to present scientific results and/or educational exhibits elaborated under supervision of experienced teachers and/or independently at national/international meetings
To continuously obtain postgraduate medical education in head and neck radiology in view of continuous professional development

Skills

To plan and to protocol contrast enhanced CT, CBCT, MRI and PET CT for the evaluation of pathologic conditions of the head and neck
To understand and to be able to adapt the parameters of MRI sequences in order to avoid poor quality images and to obtain the information necessary for the diagnosis
To be able to perform the 2D and 3D reconstructions necessary for the interpretation / illustration of findings as well as more advanced postprocessing techniques including multimodality data fusion and multiple layers reconstructions.
To be able to perform independently videofluoroscopy of deglutition, US, US guided FNAC, CT guided FNAC or US / CT guided biopsy, dacryocystography or fistulography.

Competences & Attitudes

To justify when and why a particular examination needs to be performed in the head and neck
To choose the best suited method for the assessment of pathologies of the head and neck
To communicate with the patient in order to obtain informed consent
To choose optimal imaging parameters for a given examination
To apply techniques to reduce exposure doses for CT, CBCT, videofluoroscopy of deglutition, angiography and X ray guided procedures
To supervise and teach technical staff to ensure that good quality examinations are obtained
To report the findings with respect to common and uncommon diseases
To appreciate own limitations and to identify when it is appropriate to obtain assistance
To identify urgent and/or unexpected findings in the head and neck and to communicate these timely and properly
To communicate with patients and their relatives in order to explain pathologic findings
To perform multi-disciplinary conferences and tumor boards
To be able to critically review the current literature and its applications in every day head and neck radiology
To continuously improve and adapt imaging protocols according to new technical developments
To be able to teach younger residents the basics of standard imaging interpretation in the head and neck
To be able to participate and contribute effectively to research projects initiated by experienced colleagues and/or to initiate research or educational projects involving the head and neck area
To be able to present scientific results and/or educational exhibits elaborated under supervision of experienced teachers and/or independently at national/international meetings
To continuously obtain postgraduate medical education in head and neck radiology in view of continuous professional development

European Board Examination and Diploma in Head and Neck Radiology (European Board of Head and Neck Radiology Diploma)

After a subspecialisation period of at least 2 years, the candidate is expected to take the European Board in Head and Neck Radiology (EBiHNR) Diploma examination (written and oral examination). The EBiHNR is endorsed by the European Society of Radiology (ESR). The requirements, aims and practical issues related to the examination are listed in a separate document.

Appendix 1

The anatomic areas covered by head and neck radiology include:

1. the petrous bone, the skull base and cranial nerves,
2. the orbit and visual pathways
3. the sinuses, the face and the deep spaces of the suprahyoid neck
4. the oral cavity, the pharynx and the larynx,
5. the neck, including lymph nodes and its vasculature and the deep spaces of the infrahyoid neck
6. the salivary glands
7. the mandible and temporomandibular joints
8. the thyroid gland and the parathyroid glands, the thoracic inlet and the brachial plexus