The Present Controversy over the Imaging Method of Choice for Evaluating the Soft Tissues of the Neck

The task is to discuss the controversy that exists as to the best technique for imaging the soft tissues of the neck. However, before entering into such a debate, I believe it is appropriate to first consider the definition of controversy so that any discussion might remain focused. Controversy is defined as “a dispute, especially a lengthy and public one, between sides holding opposing views; that is, a disputation as in an academic exercise consisting of a formal debate or an oral defense of a thesis” (1). As defined, there appear to be virtually no restrictions that can limit such a discussion and, as an aside, medicine at times seems to be in constant controversy. Unfortunately, we physicians no longer have the luxury of debating such problems purely within the confines of academic halls, as the economics of medicine must now be factored into the controversy. What may be philosophically the best choice may not be the practical and affordable one. Thus, any discussion of this topic can no longer exit in the “ivory tower,” but must, if you will, be tainted by the mundane reality of everyday life. In effect, there is already a restriction on the debate. I believe that a discussion of this controversy can be approached in one of two nonexclusive ways. Specifically, one can employ a general discussion of each technique, emphasizing its merits and relative weaknesses, or one can evaluate each anatomic site in the neck and debate the best choice of imaging on a site-by-site basis. In my opinion, the latter approach tends to result in a long and often rambling discussion, which may leave the reader without a clear opinion on the subject. I have chosen the former approach, with some brief site modifiers, in the hope of achieving realistic guidelines to imaging the soft tissues of the neck. To start the discussion, it should be accepted by the reader that none of these techniques can provide a reliable and precise pathologic diagnosis. To argue that one method has a greater ability to do so, particularly in cases of tumor, is to not recognize the reality of the limitations of all macroimaging techniques. Certainly, the imager can suggest a diagnosis, one that is often correct. However, clinicians who rely solely on imaging for a tumor diagnosis often leave themselves exposed to error, which can lead to incorrect treatment and possible litigation. It is true that imaging can assist the pathologist in arriving at some diagnoses, especially in cases of bone disease. However, far too often, the pathologist arrives at a different diagnosis than the one suggested by the radiologist (2–5). Thus, philosophically, one must accept that the final arbiter in this arena is the pathologist, and any discussion regarding the superiority of one imaging technique over another in arriving at a final pathologic diagnosis is prone to error, has little basis in reality, and is best left to the zealots. The mention of litigation also brings to mind the consideration of limiting one’s exposure to err by not thoroughly imaging a patient or by incorrectly interpreting the case. That is, each patient must have a thorough examination that gives the radiologist the best opportunity to arrive at a confident diagnosis. Although this concept should remain as a medical ideal, it is also one of the realities of present-day medicine and often dictates an approach to imaging. Thus, in a sense, avoidance of litigation is another restriction to the debate. Three techniques are worthy of consideration as the primary and sole means by which to image the neck: sonography, computed tomography (CT), and magnetic resonance (MR) imaging. Each has its exponents, who all too often emphasize its strengths while underplaying its weaknesses. For me, sonography is the easiest method to start with, since to many Americans its benefits are often outweighed by its limitations in the neck. In this regard, the European radiologic community has long been more ready to champion and to use sonography, and in their experience this technique may be used more often. However, in the last decade, as more CT scanners and MR imagers have become available in Europe, the number of articles advocating the strength of sonography over CT and MR imaging has decreased, while those emphasizing the use of CT and MR imaging in the neck has gained popularity (6–8). The strengths of sonography lie in its relative inexpensiveness, its ready patient compliance, and its excellent application in needle-guided biopsies of superficial structures (9, 10). Its limitations lie in its dependence on operator skill to provide reliable and accurate images and interpretations, and its propensity to be deficient when the soft tissues abut bone or an air column. Since much of neck imaging concerns either the potential deep spread of infection or the evaluation of deep tumor extension, there has been a growing tendency not to use sonography as the initial imaging examination. Invariably in these cases, a