best pediatric neck masses
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Pediatric Neck MassesPediatric Neck Masses
Mark Mark DomanskiDomanski, M.D., M.D.Michael Michael UnderbrinkUnderbrink, M.D., M.D.Dept. of Otolaryngology Dept. of Otolaryngology University of Texas Medical University of Texas Medical Branch, GalvestonBranch, GalvestonOctober 31October 31stst, 2007 , 2007
1
Total % of total
Congeital lesions 244 55% Branchial cleft cyst 78 18% Thyroglossal duct cyst 73 16% Dermoid cyst 43 10% Lymphangioma 34 8% Hemangioma 10 2% Teratoma 2 Bronchogenic cyst 2 Thymic cyst 1 Myelomeningocele 1 Inflammatory lesions 118 27% Reactive lympadenopathy 71 16% Undetermined etiology 66 15% Sinus histiocytosis 5 1% Granulomatous disease 32 7% Atypical mycobacteria 20 4% Cat scratch disease 6 1% Toxoplasmosis 2 Sarcoid 2 Suppurative lympadenitis 10 2% Sialadenitis 5 1%
Non-infammatory benign lesions
23 5%
Inclusion cyst 13 3% Fibromatosis 9 2% Keliod 1 Benign neoplasms 12 3% Neurofibroma 3 1% Lipoma 3 1% Lipoblastoma 2 Paraganglioma 1 Goiter 1 Benign mixed tumor 1 Osteoblastoma 1 Malignant neoplasms 48 11% Lymphoma 34 8% Hodgkin's 23 5% Non-Hodkin's 11 2% Thyroid Carcinoma 6 1% Rhabdomyosarcoma 2 Neuroblastoma 2 Fibrous histiocytoma 1 Acinic cell carcinoma 1 Histiocytosis X 1 Chloroma 1Total 445TorsiglieriTorsiglieri et al., 1988et al., 198822
TorsiglieriTorsiglieri et al., 1988et al., 198822
Inflammatory lesions
27%
Malignant neoplasms, 11%
Benign neoplasms3%
Non-infammatory benign lesions
5%
Congenital lesions54%
N= 445
Initial EvaluationInitial Evaluation
H&PH&PAgeAgeOnsetOnsetRapidity of growthRapidity of growthFluctuation in sizeFluctuation in sizePainPainInfectionInfectionTraumaTraumaTravelTravelExposureExposure
PEPESizeSizeMultiplicityMultiplicityLateralityLateralityConsistencyConsistencyColorColorMobilityMobilityTendernessTendernessFluctuationFluctuation
Congenital
Inflammatory
Benign
Malignant
Location, Location, Location!Location, Location, Location!
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Age of Age of DistrubtionDistrubtion Range Average (years) Brachial cleft cyst 6m – 16 y 3.6 y Thyroglossal duct cyst 9 m – 17 y 6.1 y Dermoid cyst 9 m – 15 y 3.7 y Lymphangioma 9m – 15 y 3.6 y Hemangioma 1 day – 15 y 5.6 y Reactive lymphadenopathy
3 m – 18 y 8.0 y
Graunlomatous disease
1 y – 14 y 6.0 y
Suppurative lymphadenitis
4 m – 15 y 7.3 y
Sialadenitis 11 y – 13 y 11.2 y Inclusion cyst 3 y – 12 y 4.4 y Fibriomatosis 1 m – 10 y 3.1 y Lymphoma 4 y – 21 y 11.7 y Thyroid Carcinoma 8 y – 17 y 12.3 y Others 2 weeks – 18 y 4.6 y
TorsiglieriTorsiglieri et al., 1988et al., 198822
Likely Etiology Determines Direction Likely Etiology Determines Direction of Testingof Testing
XX--rayrayU/SU/SCTCTMRIMRI
FNAFNASurgical BiopsySurgical BiopsyTissue CultureTissue Culture
CXRCXRLabsLabsPPDPPDGram stainGram stainCultureCulture
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
1. Congenital Lesions1. Congenital Lesions
Branchial cleft cyst 78 18% Thyroglossal duct cyst 73 16% Dermoid cyst 43 10% Lymphangioma 34 8% Hemangioma 10 2% Teratoma 2 Bronchogenic cyst 2 Thymic cyst 1 Myelomeningocele 1
EmbryologyEmbryology
Ectoderm, Ectoderm, mesoderm, mesoderm, endodermendoderm
Incomplete closure Incomplete closure may result in may result in branchial cleft branchial cleft anomaliesanomalies
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Development of First Four Arches
Nicollas. 20003
Each arch layer gives rise to:
•nerve (ectoderm)
•artery, muscle and cartilage (mesoderm)
•glands (endoderm).
Cyst Sinus Fistula
Schroeder. 20074
Branchial Cleft Branchial Cleft AnomaliesAnomalies
Distribution of neck malformationsas cysts, fistulas, or sinuses
per Nicollas et. al. (n=191)
Nicollas. 20003
(Sinus)
Total 139 5 47 191
Moir. 20048
Imagining in Branchial Cleft CystsImagining in Branchial Cleft Cysts
MRIMRIMore reliably confirms More reliably confirms cystic naturecystic natureMore precisely defines More precisely defines lesionlesionBetter to delineate Better to delineate glandular tissueglandular tissue
ieie fat planesfat planes
CTCTAdequate for most Adequate for most lesionslesionsCost, availabilityCost, availability
U/SU/Scystic cystic vsvs noncysticnoncysticdoes not evaluate does not evaluate extentextent
Both MRI and CT have difficulty distinguishing branchial cleft cyst from lymphangioma in children.
BranstetterBranstetter, 20069
11stst Branchial Cleft Cyst, Type IIBranchial Cleft Cyst, Type II
Type IType IEctodermalEctodermal duplication of duplication of EACEACNear external auditory Near external auditory canalcanalUsually inferior and Usually inferior and posterior to tragusposterior to tragus
Type IIType IIAssociated with Associated with submandibularsubmandibular glandgland
BranstetterBranstetter, 20069
Type 1 First Branchial Cleft CystType 1 First Branchial Cleft Cyst
Both MRI and CT have difficulty distinguishing branchial cleft cyst from lymphangioma in children.
BranstetterBranstetter, 20069
LymphangiomaLymphangioma
mass
auricle
parotid
Branchial CystBranchial Cyst
NoncalcifiedNoncalcifiedmassmass
CT shows lesion CT shows lesion under SCMunder SCM
Malik et al, 20026
22ndnd Brachial Cleft CystBrachial Cleft CystT2 MRIT2 MRI
Posterior to R Posterior to R submandibularsubmandibularglandgland
Thickened walls Thickened walls suggest prior suggest prior hemorrhage or hemorrhage or infectioninfection
Gujar and Mukherji 20045
Anterior to carotid bifurcationAnterior to carotid bifurcation
Schroeder et al, 20074
Under the anterior SCMUnder the anterior SCM
Schroeder et al, 20074
Exiting skin medial to lateral border of SCMExiting skin medial to lateral border of SCM
Schroeder et al, 20074
Left 2Left 2ndnd BA FistulaBA Fistula
Anterior to carotid bifurcationAnterior to carotid bifurcationUnder the anterior SCMUnder the anterior SCMExiting skin medial to lateral border of SCMExiting skin medial to lateral border of SCM
Schroeder et al, 20074
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22ndnd BA cyst with sinus BA cyst with sinus tract extending into tract extending into the pharynx above the the pharynx above the carotid bifurcationcarotid bifurcation
Schroeder et al, 20074
Watch the hypoglossal!
PreauricularPreauricular SinusSinus
Not related to 1Not related to 1stst
branchial cleft branchial cleft anomaliesanomaliesActive infection Active infection during excision during excision increases chance of increases chance of recurrancerecurrance
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ThyroglossalThyroglossal Duct CystDuct Cyst
persistent tract from the persistent tract from the descent of the thyroid descent of the thyroid from the foramen from the foramen cecumcecum
epithelial lining epithelial lining composed of either composed of either squamoussquamous or respiratory or respiratory epitheliumepithelium
confirm normal thyroid confirm normal thyroid tissuetissue
Learning Radiology.com200711
ThyroglossalThyroglossal Duct CystDuct Cyst
CT w/ ContrastCT w/ Contrast
Embedded in the Embedded in the strap musclesstrap muscles
Extends deep to Extends deep to involve the preinvolve the pre--epiglotticepiglottic spacespace
Gujar and Mukherji 20045
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DermoidDermoid CystsCysts
Ectoderm and mesodermEctoderm and mesoderm7% of 7% of dermoiddermoid cysts occur in head and cysts occur in head and neckneckThought to be of congenital inclusion Thought to be of congenital inclusion typetypemean diameter = 1.2 cm (0.6mean diameter = 1.2 cm (0.6--3.3)3.3)Treatment: complete excisionTreatment: complete excision
Pryor et al 200512
DermoidDermoid Cysts Cysts –– Cranial TheoryCranial Theory
GrunwaldGrunwald in 1910in 1910As As neuroectodermalneuroectodermal tract recedes, tract recedes, demaldemalattachementsattachements follow its course and can follow its course and can form a sinus or cystform a sinus or cystBeware of possible intracranial Beware of possible intracranial involvementinvolvement
Pryor et al 200512
•Orbit is the most common site for dermoids in the head and neck (61%)
•Direct excision is sufficient for neck dermoids, more extensive approaches (craniotomy, mastoidectomy) are needed for other sitesDiff Diff dxdx: in midline of neck: : in midline of neck: thyroglossalthyroglossal duct cystduct cyst
in head & neck, n = 59
Pryor et al 200512
DermoidDermoid CystsCysts
H & E
CT of dermoid cyst
Pryor et al 200512
TeratomaTeratoma
H&N account for ~2% of H&N account for ~2% of teratomasteratomasNewborn Newborn –– 2.5 yr at 2.5 yr at presentationpresentationAll 3 germinal layers presentAll 3 germinal layers presentMostly benign lesions Mostly benign lesions amenable to curative amenable to curative excisionexcision
WakhluWakhlu A et alA et al 200013
TeratomaTeratoma
•• Prognosis good if no Prognosis good if no respiratory compromiserespiratory compromise
•• Usually well Usually well differentiated and differentiated and recurrence is uncommonrecurrence is uncommon
•• Antenatal diagnosis is Antenatal diagnosis is routine in developed routine in developed worldworld
WakhluWakhlu A et alA et al 200013
TeratomaTeratoma
•• Proximity to vital Proximity to vital structures makes surgery structures makes surgery technically demanding.technically demanding.
•• Evaluate post op thyroid Evaluate post op thyroid and parathyroid function.and parathyroid function.
WakhluWakhlu A et alA et al 200013
TeratomaTeratoma –– 3 germ layers3 germ layers
Arise from Arise from pluripotentpluripotentcells and cells and ectopicectopicembryogenicembryogenicnonnon--germ germ cellscells
WakhluWakhlu A et alA et al 200013
TeratomaTeratoma –– 3 germ layers3 germ layers
WakhluWakhlu A et alA et al 200013
TeratomaTeratoma –– 3 germ layers3 germ layers
WakhluWakhlu A et alA et al 200013
HypopharyngealHypopharyngeal TeratomaTeratoma
calcified calcification and fat
Malik et al, 20026
TeratomaTeratomaT1 MRIT1 MRI
Fatty
Calcified
Gujar and Mukherji 20045
LymphangiomaLymphangioma
Benign, Benign, multiloculatedmultiloculated, soft, softPosterior neck triangle predominancePosterior neck triangle predominanceMultiMulti--septatedseptated, insinuating lesions, insinuating lesionsInfiltrate and cross tissue planesInfiltrate and cross tissue planesMost occur by 2 yrs of ageMost occur by 2 yrs of ageIncidence: 1 in 6,000 to 16,000 birthsIncidence: 1 in 6,000 to 16,000 births
BurezqBurezq 200614Head and and Neck Surgery,Head and and Neck Surgery, 200615
Lymphatic Vascular malformationLymphatic Vascular malformation
T1 MRIT1 MRI
High signal High signal represents represents proteinaceousproteinaceousfluidfluidCrosses tissue Crosses tissue planesplanes
Gujar and Mukherji 20045
Centrifugal Centrifugal vsvs CentripetalCentripetal
Centrifugal theoryCentrifugal theorythe lymphatic system develops as the lymphatic system develops as mesenchymalmesenchymalspaces that later coalesce into a system of spaces that later coalesce into a system of vessels that eventually join the venous system.vessels that eventually join the venous system.
Centripetal theoryCentripetal theoryjugular and posterior jugular and posterior lymphaticslymphatics form as form as outgrowths of endothelium from veins into the outgrowths of endothelium from veins into the surrounding surrounding mesenchymemesenchyme..
BurezqBurezq 200614
ClassificationClassification
Size:Size:MicrocysticMicrocystic: capillary : capillary lymphangiomaslymphangiomas
lesions are less than 1 cm in diameterlesions are less than 1 cm in diameter
MacrocysticMacrocystic: cystic : cystic hygromashygromascysts are larger than 1 cmcysts are larger than 1 cm
Cystic Cystic hygromashygromas #1 type of #1 type of lymphangiomalymphangioma
Gross et al, 200616
Cystic Cystic HygromaHygroma
NoncalcifiedNoncalcified
SeptatedSeptated on on U/SU/S
Malik et al, 20026
Cystic CompositionCystic Composition
55--yearyear--old boy with old boy with lymphangiomalymphangiomaL parotid & L parotid & parapharyngealparapharyngeal spacespacemixed macromixed macro--andmicrocysticandmicrocystic typetypeTreated by surgical Treated by surgical resectionresection
Gross et al, 200616
Type 1 First Branchial Cleft CystType 1 First Branchial Cleft Cyst
Both MRI and CT have difficulty distinguishing branchial cleft cyst from lymphangioma in children.
BranstetterBranstetter, 20069
LymphangiomaLymphangioma
mass
auricle
parotid
BurezqBurezq et al, 2006et al, 2006(expert opinion)(expert opinion)
1. Error in establishing a communication 1. Error in establishing a communication between the lymphatic and venous systembetween the lymphatic and venous system
Cystic Cystic hygromahygroma
2. Error in morphogenesis of lymphatic system: 2. Error in morphogenesis of lymphatic system: this includes other types of lymphatic this includes other types of lymphatic malformationsmalformations
microcysticmicrocystic, , macrocysticmacrocystic and mixed lymphatic lesionsand mixed lymphatic lesions
BurezqBurezq 200614
Management Management -- ControversialControversial
Spontaneous resolution?Spontaneous resolution?Formation of new lymphatic channels?Formation of new lymphatic channels?
Serial aspiration?Serial aspiration?
SclerosantSclerosant Agents?Agents?OKOK--432 (432 (lyophiliziedlyophilizied mixture of lowmixture of low--virulence group A virulence group A SterpSterppyogenspyogens
Surgical Excision?Surgical Excision?Is the surgical risk out weigh the benefit in a benign lesionIs the surgical risk out weigh the benefit in a benign lesion
BurezqBurezq 200614
Success with Serial AspirationsSuccess with Serial Aspirations
BurezqBurezq 200614
Success with OKSuccess with OK--432432
Supraclavicular macrocysticlymphangioma
Gross et al, 200616
HemangiomaHemangioma
Less than 1/3 present at birthLess than 1/3 present at birthUsually seen in 1Usually seen in 1stst few months of life and few months of life and enlarge progressivelyenlarge progressively90% cases involutes spontaneously90% cases involutes spontaneouslySclerosingSclerosing agents controversialagents controversial
GlutGlut--11
erythrocyteerythrocyte--type glucose transportertype glucose transporter
found only in found only in microvascularmicrovascular endothelia of bloodendothelia of blood––tissue tissue barriers such as in the central nervous system, retina, barriers such as in the central nervous system, retina, placenta, placenta, ciliaryciliary muscle, and muscle, and endoneuriumendoneurium of peripheral of peripheral nervesnerves
HemangiomasHemangiomas stain consistently for Glutstain consistently for Glut--1, in all stages 1, in all stages of development and involution whereas vascular of development and involution whereas vascular malformations did notmalformations did not
Mo et al, 200617
MacArther, 200618
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
2. Inflammatory Lesions2. Inflammatory Lesions Reactive lympadenopathy 71 16% Undetermined etiology 66 15% Sinus histiocytosis 5 1% Granulomatous disease 32 7% Atypical mycobacteria 20 4% Cat scratch disease 6 1% Toxoplasmosis 2 Sarcoid 2 Suppurative lympadenitis 10 2% Sialadenitis 5 1%
When does cervical When does cervical lymphadenopathylymphadenopathy require FNA? require FNA?
Benign reactive lymph node may persist Benign reactive lymph node may persist for weeks to monthsfor weeks to monthsLymphoma can present the same wayLymphoma can present the same way
Rapkiewicz et al 200721
To FNA or not to FNA? To FNA or not to FNA?
Reactive Reactive lymphadenopathylymphadenopathy the most likely the most likely etiology of pediatric neck massesetiology of pediatric neck masses
Diagnostic Diagnostic dilemadilema: a mass that does not : a mass that does not resolve after initial treatmentresolve after initial treatment
Rapkiewicz et al 200721
FNA ancillary studiesFNA ancillary studies
Gram stain, cultureGram stain, cultureAcid fast stainAcid fast stainImunocytochemistryImunocytochemistryCytogeneticsCytogenetics
Rapkiewicz et al 200721
Limitations to FNALimitations to FNA
A lesion may not be homogenousA lesion may not be homogenousFNA samples only part of the massFNA samples only part of the massMay miss the true lesionMay miss the true lesion
Unable to appreciate histological Unable to appreciate histological architecturearchitecture
Rapkiewicz et al 200721
Time to contemplate open biopsyTime to contemplate open biopsy
Enlarging massEnlarging massPoor response to medical treatmentPoor response to medical treatmentSuspicious clinical courseSuspicious clinical courseUnusual image findingsUnusual image findingsSystemic symptomsSystemic symptoms
Rapkiewicz et al 200721
Case Case –– F.R.F.R.
8 8 y/oy/o female, female, hxhx + PPD several yrs prior+ PPD several yrs priorPresents with R cervical Presents with R cervical adenopathyadenopathyFNA suggests FNA suggests granulomagranulomaRepeat FNA Repeat FNA --> same result> same resultAFB stain and cultures negativeAFB stain and cultures negativeClarithromycinClarithromycin and and ethambutolethambutol startedstarted
Rapkiewicz et al 200721
Case Case –– F.R.F.R.
AdenopathyAdenopathy and pain increasedand pain increasedThird FNA nonThird FNA non--diagnosticdiagnosticCT shows bulky homogenous CT shows bulky homogenous lymphadenopathylymphadenopathy of R upper spinal of R upper spinal accessory and upper jugular chains.accessory and upper jugular chains.Open biopsy displayed Open biopsy displayed Hodgkin's Hodgkin's lymphoma.lymphoma.
Rapkiewicz et al 200721
Reactive Reactive LymphadenopathyLymphadenopathy
33--yearyear--old childold childMultiple Multiple hypoechoichypoechoiclesionslesionsvariable shape and variable shape and sizessizesconsistent with consistent with reactive lymph reactive lymph nodesnodes
Malik et al, 20026
Enlarged Lymph NodeEnlarged Lymph Node
NonspecificNonspecific
Cause:Cause:cryptococcalcryptococcaladenitisadenitisYeastlikeYeastlikefungusfungus
Gujar and Mukherji 20045
Atypical Atypical mycobacteriamycobacteria: ex: : ex: cryptococcuscryptococcus
Saprobe in Saprobe in naturenatureworldwide worldwide distributiondistributionFound in soilFound in soilPortal of entry Portal of entry is lungis lung
Atypical Atypical mycobacteriamycobacteria: ex: : ex: cryptococcuscryptococcus
Associated w/Associated w/AIDSAIDSorgan organ transplantationtransplantationLymphoreticularLymphoreticulardiseasesdiseases
½½ pts lack pts lack apprarentapprarentpredisposing predisposing factorsfactors
BartonellaBartonella henselaehenselae
HypoechoicHypoechoic masses masses with irregular rim of with irregular rim of isoechoicisoechoic tissuetissue
Biopsy: Cat Scratch Biopsy: Cat Scratch DiseaseDisease
Malik et al, 20026
BartonellaBartonella henselaehenselae
Gram Gram –– coccobacilluscoccobacillus22-- 14 day incubation14 day incubationDxDx: requires prolonged : requires prolonged incubation (2 + weeks)incubation (2 + weeks)Rx: erythromycin 1Rx: erythromycin 1--4 m 4 m (unclear efficacy)(unclear efficacy)Normally benign courseNormally benign course
Malik et al, 20026
In heart valve
PeritonsillarPeritonsillar AbcessAbcess
Soft tissue density in Soft tissue density in submentalsubmental spacespace
Malik et al, 20026
Retropharyngeal Retropharyngeal AbscessAbscess
Widening of Widening of prevertebralprevertebral spacespace
Malik et al, 20026
Retropharyngeal Space AbscessRetropharyngeal Space Abscess
Gujar and Mukherji 20045
RetropharyngealPeritonsillar
Malik et al, 20026
SppurativeSppurative Cervical AdenitisCervical Adenitis
hypoechoic
Malik et al, 20026
Thyroid AbscessThyroid Abscess
Malik et al, 20026
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
3. Non3. Non--inflammatory Benign inflammatory Benign LesionsLesions
Inclusion cyst 13 3% Fibromatosis 9 2% Keloid 1
Inclusion CystInclusion Cyst
Acquired Acquired dermoiddermoid cystscystsresult from a part of the skin being traumatically result from a part of the skin being traumatically implanted in the deeper layers after implanted in the deeper layers after ectopicectopic formation formation of a of a dermal cyst lined with dermal cyst lined with squamoussquamousepitheliumepithelium..
Congenital inclusion Congenital inclusion dermoiddermoid cysts form along cysts form along the lines of embryologic fusion and contain both the lines of embryologic fusion and contain both dermal and epidermal derivatives.dermal and epidermal derivatives.
DermoidDermoid cysts of the head and neck are thought to be cysts of the head and neck are thought to be the congenital inclusion type. the congenital inclusion type.
Pryor et al 200512
Inclusion CystInclusion Cyst
many cysts originate from the many cysts originate from the infundibularinfundibularportion of the hair follicle, and the more portion of the hair follicle, and the more general term, general term, epidermoidepidermoid cystcyst, is favored, is favored
Becker et a, 200519
Epidermal Inclusion CystEpidermal Inclusion Cyst
Cyst containing keratinous material true epidermis with a granular layer and adjacent laminated keratinous material
Becker et al, 200519
TorticollisTorticollis
FibromatosisFibromatosis ColliColli
SCMSCMIsoechoicIsoechoic massmass
CT shows CT shows isodenseisodensemass R sidemass R sideNote normal SCM on Note normal SCM on L sideL side
Malik et al, 20026
FibromatosisFibromatosis ColliColli -- FNAFNA
PaucicellularPaucicellularspecimenspecimen
Bland spindle Bland spindle cell cytologycell cytology
r/or/o nodular nodular fascitisfascitis and and fibrosarcomafibrosarcoma
Rapkiewicz et al 200721
FibromatosisFibromatosis ColliColli
r/or/o nodular nodular fascitisfascitis and and fibrosarcomafibrosarcoma
Roy, 200720
Moir. 20042
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
4. Benign Neoplasms4. Benign Neoplasms
Neurofibroma 3 1% Lipoma 3 1% Lipoblastoma 2 Paraganglioma 1 Goiter 1 Benign mixed tumor 1 Osteoblastoma 1
NeurofibromaNeurofibroma
solitary lesionsolitary lesionvsvs
part of the generalized syndrome of part of the generalized syndrome of neurofibromatosisneurofibromatosis
NFNF--1, aka von Recklinghausen disease1, aka von Recklinghausen diseaseNFNF--22
Believed to arise from Schwann cell but Believed to arise from Schwann cell but origin uncertainorigin uncertain
NeurofibromaNeurofibroma
solitary lesionsolitary lesionvsvs
part of the generalized syndrome of part of the generalized syndrome of neurofibromatosisneurofibromatosis
NFNF--1, aka von Recklinghausen disease1, aka von Recklinghausen diseaseNFNF--22
Believed to arise from Schwann cell but Believed to arise from Schwann cell but origin uncertainorigin uncertain
NeurofibromaNeurofibroma
T2 MRIT2 MRI
Central low T2 Central low T2 signal is signal is characteristic of characteristic of neurofibromasneurofibromas
Gujar and Mukherji 20045
LipoblastomaLipoblastoma
Rare benign Rare benign mesynchymalmesynchymaltumor of tumor of embryonalembryonal fatfat
May clinically and May clinically and radiologicallyradiologicallymimic a mimic a hemangiomahemangioma
Collections of Collections of lipoblastslipoblasts ––multivuolatedmultivuolated w/ round nucleiw/ round nuclei
FNA
LipoblastomaLipoblastoma
Resembles Resembles embryological adipose embryological adipose tissuetissue
Surgical specimen
LipomaLipoma LipoblastomaLipoblastoma
Neonatal Neonatal GoiterGoiter
CT shows large peripheral rim CT shows large peripheral rim enhancing, low attenuation enhancing, low attenuation massmass
1: 4000 live births1: 4000 live births
Female 2x = Male Female 2x = Male predominancepredominance
Delayed ossification at bone Delayed ossification at bone endsends
Malik et al, 20026
Rovet et al, 200310
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
Pediatric Neck MassesPediatric Neck Masses
1. Congenital lesions1. Congenital lesions2. Inflammatory lesions2. Inflammatory lesions3. Non3. Non--inflammatory benign lesionsinflammatory benign lesions4. Benign 4. Benign neoplasmsneoplasms5. Malignant 5. Malignant neoplasmsneoplasms
5. Malignant Neoplasms5. Malignant Neoplasms
Lymphoma 34 8% Hodgkin's 23 5% Non-Hodkin's 11 2% Thyroid Carcinoma 6 1% Rhabdomyosarcoma 2 Neuroblastoma 2 Fibrous histiocytoma 1 Acinic cell carcinoma 1 Histiocytosis X 1 Chloroma 1
LymphomaLymphoma
Third most common pediatric cancerThird most common pediatric cancerIncidence: 11Incidence: 11--20 per million children20 per million childrenGeographical variance Geographical variance –– 50 % of 50 % of childhood cancers in equatorial Africachildhood cancers in equatorial Africa
Due to high incidence of Due to high incidence of BurkittBurkitt’’ss lymphomalymphoma
Male predominance 2.5:1Male predominance 2.5:1
Beware the Beware the supraclavicularsupraclavicular mass!mass!
35% of patients 35% of patients with H&N with H&N lymphoma lymphoma present with a present with a supraclavicularsupraclavicularmassmass
35% of pts with 35% of pts with suprclavicularsuprclavicularmasses had masses had lymphomalymphoma
Turkington et al 200522 TorsiglieriTorsiglieri et al., 1988et al., 198822
NeuroblastomaNeuroblastoma
NoncontrastNoncontrast T1 T1 MRIMRI
Mass (arrow) Mass (arrow) lateral to carotid lateral to carotid artery artery (arrowhead).(arrowhead).
Gujar and Mukherji 20045
RhabdomyosarcomaRhabdomyosarcoma -- CTCT
Ill definedIll defined
enhancing soft enhancing soft tissue densitytissue density
areas of necrosisareas of necrosis
Malik et al, 20026
RhabdomyosarcomaRhabdomyosarcomaof the Masticator Spaceof the Masticator Space
NonNon--contrast T1 contrast T1 –– intermediate intermediate signalsignal
T2 T2 –– increased signalincreased signal
Gujar and Mukherji 20045
TorsiglieriTorsiglieri et al., 1988et al., 198822
Inflammatory lesions
27%
Malignant neoplasms, 11%
Benign neoplasms3%
Non-infammatory benign lesions
5%
Congenital lesions54%
N= 445
Total % of total
Congeital lesions 244 55% Branchial cleft cyst 78 18% Thyroglossal duct cyst 73 16% Dermoid cyst 43 10% Lymphangioma 34 8% Hemangioma 10 2% Teratoma 2 Bronchogenic cyst 2 Thymic cyst 1 Myelomeningocele 1 Inflammatory lesions 118 27% Reactive lympadenopathy 71 16% Undetermined etiology 66 15% Sinus histiocytosis 5 1% Granulomatous disease 32 7% Atypical mycobacteria 20 4% Cat scratch disease 6 1% Toxoplasmosis 2 Sarcoid 2 Suppurative lympadenitis 10 2% Sialadenitis 5 1%
Non-infammatory benign lesions
23 5%
Inclusion cyst 13 3% Fibromatosis 9 2% Keliod 1 Benign neoplasms 12 3% Neurofibroma 3 1% Lipoma 3 1% Lipoblastoma 2 Paraganglioma 1 Goiter 1 Benign mixed tumor 1 Osteoblastoma 1 Malignant neoplasms 48 11% Lymphoma 34 8% Hodgkin's 23 5% Non-Hodkin's 11 2% Thyroid Carcinoma 6 1% Rhabdomyosarcoma 2 Neuroblastoma 2 Fibrous histiocytoma 1 Acinic cell carcinoma 1 Histiocytosis X 1 Chloroma 1Total 445TorsiglieriTorsiglieri et al., 1988et al., 198822
ConclusionsConclusions
Initial evaluation (H&P)Initial evaluation (H&P)Congenital, infectious, benign, malignantCongenital, infectious, benign, malignant
Beware of tuberculosis, cat scratch Beware of tuberculosis, cat scratch disease, atypical infectionsdisease, atypical infectionsBeware of systemic symptomsBeware of systemic symptomsBeware the Beware the supraclavicularsupraclavicular massmassConsider FNA or biopsy in the mass that Consider FNA or biopsy in the mass that does not resolve with treatment.does not resolve with treatment.
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