head and neck masses in children
TRANSCRIPT
Neck Masses in Children
Felice D’ArcoDiagnostic Imaging
Great Ormond Street Hospital For Children
A Practical Guide to the Differential Diagnosis
felice.d’[email protected]
Summary
o Essential Anatomy of The Neck Superficial Fascia (subcutaneous Tissue) Neck Spaces (3 layers of the deep
cervical fascia)o Features of the Lesion: Where? Cystic?
Solid?
Anatomy of the Neck Superficial Cervical Fascia: thin layer
of subcutaneous connective tissue that lies between the dermis of the skin and the deep cervical fascia
Contents: platysma, nerves, blood /
lymphatic vessels, fat. Pathology (related to the
content!!): Teratoma, Vasc. Malformations/neoplasm, Cellulitis, Plexiform Neurofibromas (NF1), Subcutaneous Fat Fibrosis (neonates)
NB: It is considered by some to be a part of the Panniculus adiposus, and not true fascia. Bailey, B.J. Ed: Head and Neck Surgery-Otolaryngology 2006.
Superficial Cervical Fascia (yellow)
From internet
Subcutaneous fat tissue between the skin and the superficial layer of the deep cervical fascia (green)
Superficial layer DCF
Skin
Anatomy of the Neck Deep Cervical Fascia (DCF): 3 layers
superficial (SL), middle (ML) and deep (DL)
The layers divide neck in compartments (on the axial plane).
Neck is also divided in Suprahyoid neck (SHN) Infrahyoid neck (IHN) (on the coronal and sagittal plane)
Hyoid Bone
Superficial Layer DCFSHN: Around Masticatory Sp. & Parotid Sp;
part of carotid space
www.statdx.com
Superficial layer DCF
Superficial Layer DCFIHN: surrounds strap,
sternocleidomastoid & trapezius muscles
www.statdx.com
Superficial layer DCF
Middle Layer DCFSHN: defines Pharyngeal Mucosal Space deep margin; contributes to
carotid space
www.statdx.com
ML - DCF
Middle Layer DCFIHN: Surrounds Visceral Sp.; contributes of carotid space
www.statdx.com
ML - DCF
Deep Layer DCF
www.statdx.com
SHN & IHN: Surrounds perivertebral space (paraspinal and pre-vertebral components), Contributes to carotid space.
DL - DCF
Deep Layer DCF: Alar FasciaPart of the DL-DCF which forms the lateral and posterior walls of the
Retropharyngeal space and separates this space from the Danger Space (virutal space)
www.statdx.com
DS: from the skull base to the mediastinum; Boundaries ANT:
Retropharyngeal Sp. POST: pre-vertebral component of periveterbal space
Neck Masses in Children: Solid
Reactive/metastatic Lymph nodes Lymphoma Infantile Hemangioma Rhabdomyosarcoma Lipoma Matastatic Neuroblastoma (mostly
osseous); Primary Neck Neuroblastoma (posterior carotid space)
Fibromatosis Colli (neonate)
Neck Masses in Children: Cystic
Thyreoglossal Duct Cyst Laryngocele Abscess Branchial Cleft Cyst Lymphatic Malformation Dermoid/Epidermoid Teratoma (mixed solid and cystic)
Space or Anatomic region Differential DiagnosisSuperficial Fascia Teratoma, Vascular Malformations, lipoma, plexiform
Neurofibroma, fibromatosis colli of SCM (in neonates)Danger Sp. Cellulitis/Abscess
Masticator Sp. Venous/lymphatic Malf., rhabdomyosarcoma, cellulitis/abscess
Parotid Sp. Infection, Lymphatic malf., RMV thrombosisCarotid Sp. IJV thrombosis, lymphadenopathy, abscess,
neuroblastomaRetropharyngeal Sp. Cellulitis/Abscess, extension of tumours or goiter
Perivertebral Sp. Neuroenteric cyst, Cellulitis/Abscess, Spondylodiskitis
Posterior Cervical Sp.
Lymphatic malf., lymphadenopathy, lymphoma
Submandibular/Sublingual Sp.
Thyroglossal cyst, venous/lymphatic Malf, dermoid cyst, ranula, sublingual gland disease
Pharyngeal and Parapharyngeal Sp.
Lymphangioma, paraganglioma, rhabdomyosarcoma, abscess, Lymphoma
Infantile Hemangioma : can occur in any space!
Solid Neck Masses
Reactive Lymph Nodes
Most frequent solid “masses” in children Benign, reversible enlargement of nodes in
response to antigen stimulus Acute/Chronic; Localized/Generalized IMAGING: Multiple well-defined, oval-shaped nodes that
can be enlarged (> 2 cm in children), typically oval-shaped rather than round, mild homogeneous enhancement
CECT appearance Do not forget the levels of the Neck !
Drawing by F. Gaillard
Tonsils
Leve
l II
A
Level II A
Level V a
Differential Diagnosis1) METASTATIC NODES
Rare in children
Bigger size (but in children this criterion does not work as in adult!)
Round node shape rather than oval
Clustered nodes
Focal nodal defect/necrosis
Extracapsular spread
Primary Tumor! NB: DD between Meta Nodes and Suppurative Nodes is often obvious clinically (Hot, tender, febrile patient)
Christine M. Glastonbury
Differential Diagnosis2) Lymphoma (NHL and HL) - SIZE ! BILATERAL non-symmetric!
-Posterior Cervical Space often involved
-Homogeneous lobulated nodal masses
-Single or multiple nodal chain
-Variable contrast enhancement
-Necrotic center may be present
Lymphoma Neck
Internal jugular chainSpinal Accessory Chain
4 yo HL
Bilateral Internal jugular chain
Infantile Hemangioma
Can be in different locations in the neck (subcutaneous tissue)
Is a benign neoplasm (not malformation) Proliferative phase: few weeks after birth to 1-2
years Involuting phase: gradual regression over next
several years (90% resolve by 9 years) Often single lesion.
IMAGING Key Features: Well-defined enhancing mass, mildly hyper T2 to
muscle Internal Vessels (Serpiginous Flow Voids) No Calcifications! (DD Venous Malformation) US: mean venous peaks not elevated (DD AVM) Involuting Phase: fatty replacement
Infantile Hemangioma
First Diagnosis
After Treatment with Propanolol
Differential Diagnosis
1) Venous Malformation
Large venous lakes - T2 signal more hyperintense
- Variable enhancement (patchy, heterogeneous)
- Phleboliths: Calcium within the lesion
- No Flow voids
Differential Diagnosis2) AVM- High flow and tortuous
feeding arteries
- Large draining veins
- Nidus/AV shunting
- Ill defined mass
- US: elevated venous peaks
- Worsening overtime
- Clinical: arterial feeding is evident
Differential Diagnosis3) Rhabdomyosarcoma- Different age : 2- 5 y; 15-19 y
- Aggressive behavior: bony erosion, invasions surrounding tissues
- Non-Homogeneous appearance (necrosis, hemorrhage) and contrast
- Diffusion restriction (Lope 2012)
Rhabdomyosarcoma Neck
Rhabdomyosarcoma Neck
T2 signal, hyper but not too much
statdx.com
Fat signal/ density in all sequences, if associated c.e. suspect liposcarcoma
Lipoma
CT: Low Density ( −100 to −50 HU)
Hyper in T1 Suppressed in Fat-Sat
Metastatic : Typical Osseous Meta in Calvarium, Skull base, Orbits, Temporal bones DWI restriction, c.e.
Radiologist need to suggest abdominal US MIGB uptake Rare Nodal Metastasis
Neuroblastoma
Primary Neck NB : Posterior Carotid Space
1-5 % of NB Moderately enhancing mass Associated Lymphoadenopathy DD with Reactive Nodes and
Lymphoma very difficult (biopsy) Presence of Ca++ (extremely rare
in Lymphoma)
Neuroblastoma
Sternocleidomastoid Enlargement of Infancy Appears within 2 weeks of delivery; regresses by 8
months Nontender (DD with myositis) , monolateral Enlargement of the muscle which enhances diffusely Surrounding tissues are normal (DD with
Rhabdomyosarcoma together with age) Diagnosis: Clinical + US
Fibromatosis Colli
Normal Fibromatosis Colli
Smiti et al.2010
Dr. B. Koch
Cystic Neck Masses
Remnant of the TGD (Between foramen cecum at tongue base → thyroid bed in infrahyoid neck)
Most common congenital neck lesions
Median cyst (could be also paramedian in the infrahyoid neck)
Thin rim of c.e. is possible (often associated with infection)
Embedded by strap muscles when infrahyoid (“claw sign”)
Thyroglossal Duct Cyst
Harnsberger 2004
Differential Diagnosis
1)Lingual Thyroid- Solid, enhancing
mass
- Ectopic Thyroid Tissue in the base of the tongue or floor of the mouth
Differential Diagnosis
2) Laryngocele - Traces back to the
Larynx
- Air and fluid
Differential Diagnosis3) Median Sub-
Lingual Abscess - Clinical: associated
Odontogenic or salivary gland infection
- Thick enhancing wall, DWI restriction in MRI
Harnsberger 2004
NB: most frequent location of an abscess in neck is retropharyngeal space
Congenital malformations during development of the branchial apparatus
4 types of branchial cleft anomalies: cysts, sinuses, fistulas from the 1st , 2nd, 3rd and 4th branchial arches
2nd branchial cleft anomaly is the most common: 95%
Branchial Cleft Anomalies
Head and neck region at 4 weeks gestation (Meuwly et al 2005)
Unilocular cysts with thin wall Fluid content: CT hypodense, T1
hypohintense, T2 hyperintense No enhancement or subtle wall enhancement If infected: wall thickening/enhancement,
increase density of the fluid Neoplastic degeneration: enhancing nodules
along the wall
Branchial Cleft Anomalies
1st Branchial Cleft Anomaly
Benign, congenital cyst in or adjacent to parotid gland, EAC, or pinna
Several classifications related to embryology or location
Postero-inferior to auricle Adjacent to parotid gl./mandible angleB. Koch 2015
2nd Branchial Cleft Anomaly
Typical location: Antero-medially to the SCM (superior 1/3), posteriorly to the submandibular gland, laterally to the carotid space
B. Koch 2015
3rd Branchial Cleft Anomaly- Medially to the middle 1/3 of the
SCM- Lower than 2nd BCC
- In the posterior cervical space
Carotid sp
3BCC
SCM
Post Cerv Sp
4th Branchial Cleft AnomalyIt is a tract from the pyriform sinus to the
Superior aspect of the thyroid
Thyroid
B. Koch 2015
Uni- or multiloculated, non-enhancing, cystic neck mass.
Micro- and macro cystic Often trans-spatial, with fluid-fluid levels
(hemorrhage and high proteinaceous components)
Venolymphatic Malf. : Combined elements of venous malformation & lymphatic malformation (contrast enhancement of the venous elements)
Lymphatic Malformation
2nd BCC: unilocular cyst, typical location, no fluid-fluid levels
Abscess/suppurative nodes: clinical signs of infection, peripheral enhancement and cellulitis
Thyroglossal duct cyst: typical (midline) location, single cyst
Differential Diagnosis
Dermoid/Epidermoid Cyst
Definition: Cystic mass resulting from congenital epithelial inclusion or rest
Epidermoid: Epithelial elements only, fluid content Dermoid: Epithelial elements plus dermal
substructure, fluid, fatty or mixed content Location: oral cavity (DD with Ranula and TGDC),
midline anterior neck (DD with TGDC), orbit (DD with abscess and lymphatic malf.), nasal with associated nasal dermal sinus ± intracranial extension
Imaging
Epidermoid: homogeneous T1 hypo and T2 hyper. Increase T1 signal if high protein fluidDermoid: heterogeneous signal. Fatty elements are T1 hyper and low in fat sat T2. Possible Ca++Both can have DWI restriction and thin rim enhancement
T1 T2 fat-sat
T1
Dermoid: tyipical “sac of marbles” appearance due to area of fatty
attentuation
Malik et al. 2012
Differential Diagnosis Ranula: salivary gland retention cyst in
sublingual space. Can be indistinguishable from epidermoid
cyst which doesn’t show restriction. Often is ruptured into the submandibular
space (diving ranula) which shows typical “comet shape” (body in the SMS and tail in the SLS)
No fat, no Ca++ and no DWI restriction
Malik et al. 2012
Tail
Body
Teratoma Anterior neck, midline mass containing all 3
germ layers Mixed (cystic and solid) with fat and
calcium DD: Lymphatic Malf (fluid with no fat, calcium
or solid components), Goiter (homogeneous, respects limits of the thyroid gland)
Mixed solido-cystic mass with fat content
Neck masses are common findings in children and can be a diagnostic challenge
Often trans-spatial No space-specificity Distinction in Solid or Cystic (or mixed) can
help in the differential diagnosis
Conclusion
Thank you